TIMI Grade Research Articles

Admission heart failure and coronary perfusion in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Studies demonstrated a link between the presence of HF on the admission of ACS patients and increased in-hospital morbidity and mortality. However, the literature did not establish the connection between the admission HF and the angiographic burden and the coronary vessel perfusion post-PPCI. Purpose To establish the correlation between acute HF on admission of STEMI patients, the coronary thrombus burden and the final coronary perfusion post PPCI. Methods We retrospectively studied 210 STEMI patients who presented to a single PPCI centre. We excluded post-fibrinolysis patients, patients with old stents and those who presented more than 24 hours after the onset of pain. We divided the studied cohort into two subgroups based on the presence of HF on presentation to the emergency department. We obtained Informed consent from all patients, and all procedures were done in compliance with the Helsinki declaration for research on human beings. Two blinded interventional cardiology consultants assessed the thrombus burden and coronary flow using TIMI grades of both variables. Results 20 patients (10%) of the studied group had HF on admission. There was no significant difference between the two subgroups regarding other cardiovascular risk factors (figure 1). The coronary thrombus burden did not differ significantly between the HF and no HF subgroups (50% vs 43.16%, respectively, p=0.557). However, the incidence of impaired coronary flow post-PPCI was significantly higher in the HF group (25% vs 8.4%, p=0.019) (figure 2). Multivariate logistic regression analysis showed that admission HF is an independent predictor of impaired perfusion post-PPCI ( OR= 5.49, 95% CI=1.54-19.49, p=0.01). Our study demonstrates the association between admission HF in STEMI patients undergoing PPCI and increased incidence of impaired coronary flow after PPCI. This finding was independent of the heavy coronary thrombus burden on angiography. Animal studies have demonstrated impaired coronary flow even in HF secondary to non-ischaemic causes.1,2 Possible mechanisms include impaired nitric oxide-mediated endothelium-dependent vasodilatation and enhanced vasoconstriction to mediators of neurohumoral activation.3 These mechanisms can explain our study's impaired coronary flow in HF patients. Conclusion Admission HF is an independent predictor of reduced coronary blood flow after PPCI. Timely treatment of STEMI patients can prevent HF development and improve their prognosis.

Benefits of excimer laser coronary angioplasty over thrombus aspiration therapy for patients with acute coronary syndrome and thrombolysis in myocardial infarction flow grade 0.

In primary percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), the presence of a thrombus or unstable plaque can cause microvascular obstructions, which may increase infarct size and reduce survival. Excimer laser coronary angioplasty (ELCA) is a unique revascularization technique that can vaporize plaques and thrombi. However, to date, only few reports indicate the efficacy of ELCA for ACS. We retrospectively analyzed 113 consecutive ACS patients who underwent PCI with either ELCA or manual thrombus aspiration therapy (TA) before balloon angioplasty or stenting and who had a Thrombolysis in Myocardial Infarction flow (TIMI) grade 0 on the first contrast injection within 24h of onset at our hospital from March 2011 to March 2020. Patients were divided into two groups by the procedure used: ELCA (N = 48) and TA (N = 50). Door-to-reperfusion time was significantly shorter in the ELCA group than TA group (89.2 ± 6.7 vs. 137.9 ± 12.3min, respectively; P < 0.01). There was also a significant difference in peak creatine kinase-myocardial band between the ELCA and TA groups (242 ± 25 vs. 384 ± 63IU/L, respectively; P = 0.04). Although there was no difference in myocardial blush grade (MBG) before treatment, the MBG after treatment was higher in the ELCA group (P < 0.01). In-hospital major adverse cardiac events (MACE) were also significantly fewer in the ELCA group than in the TA group (8% vs. 20%, P = 0.045). ELCA for TIMI grade 0 ACS may shorten reperfusion time, improve the MBG score, and reduce MACE when compared to TA.

The Outcome of Intracoronary Tirofiban Administation at Primary Percutenous Coronary Intervention in ST-Elevation Myocardial Infarction Patients

Background and Aim: Thrombosis within the coronary arteries causes ST-elevation myocardial infarction. STEMI can be vascularized by primary PCI, which is class-I indication and the gold standard. The present study aimed to assess the outcome of pericardial tirofiban administration in patients with ST-level myocardial infarction following primary percutaneous coronary intervention. Patients and Methods: This cross-sectional study was conducted on 228 ST-elevation myocardial infarction (STEMI) patients in the Bahawalpur Heart Center, Bahawalpur for the duration of Six months from March 2022 to September 2022. Patients of both gender having an age range 25 to 65 years with STEMI were enrolled and categorized into two groups based on Tirofiban administration are as follows: Group-I comprised of Tirofiban group and Group-II control (non-tirofiban group). All the patients underwent primary percutaneous coronary intervention (PCI). Major bleeding, MACE, TIMI Grade flow, hematoma, myocardial blush, minor bleeding, and mortality were different variables measured. SPSS version 28 was used for data analysis. Results: The overall mean age was 42.82± 10.26 years. Of the total 228 STEMI patients, there were 166 (72.8%) male and 62 (27.2%) were females. The mean age of group-I (n=114) and group-II (n=114) was 41.74 ± 11.62 years and 43.9± 8.9 years. The age-wise distribution of patients were as follows: 74 (32.5%) in 25-35 years, 70 (30.7%) in 36-45 years, 64 (28.1%) in 46-55 years, and 20 (8.8%) in 56-65 years. The prevalence of hypertension, diabetes, and smoker in Tirofiban and non-tirofiban group was 32 (28.1%) vs. 34 (29.8%), 24 (21.1%) vs. 28 (24.6%), and 31 (27.2%) vs. 33 (28.9%) respectively. A p-value of 0.05 indicated that there was an independent difference in TIMI flow grades between the two groups. Based on clinical outcomes, the incidence of partial reperfusion TIMI flow grade, normal myocardial blush grade, major bleeding, MACE, hematoma, minor bleeding, and mortality was found in 72 (31.6%), 146 (64%), 60 (26.3%), 68 (29.8%), 61 (26.8%), 52 (22.8%), and 8 (3.5%) respectively. Conclusion: The present study found that patients with severe thrombus burden and STEMI who underwent emergency coronary intervention received intracoronary tirofiban treatment that was simple, safe, and effective. A significant difference in TIMI flow and myocardial blush grades was observed when intracoronary Tirofiban was administered to STEMI patients undergoing percutaneous coronary intervention compared with patients who did not receive intracoronary Tirofiban. Keywords: Intracoronary Tirofiban, Percutaneous coronary intervention, ST-elevation myocardial infarction, Outcomes

Abstract 13011: A Rare Case of Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare condition; an intimal tear or bleeding of vasa vasorum leads to the creation of a false lumen filled with intramural hematoma. The hematoma causes coronary stenosis, leading to subsequent myocardial ischemia. SCAD is the cause of Acute Coronary Syndrome (ACS) in 0.1 to 4% of cases. Men account for less than 10% of cases, with a mean age of 48.6. Case Study: A 19-year-old male with prior medical history of morbid obesity and marijuana use was transferred from another hospital to our service after presenting with non-ST elevation MI. He was admitted following 30 minutes of a throbbing/pressure-like sensation in his throat, one episode of vomiting, and paresthesia in his left arm that spontaneously resolved. Initial EKG showed sinus rhythm with early repolarization changes. His troponin rose from 0.2 to 18 ng/mL. Upon admission, his high sensitivity troponin peaked at 15,000 pg/mL. Repeat EKG showed dynamic changes with T wave inversions in the inferolateral leads. The patient underwent an angiogram showing a diffuse, mid-LAD 40% de novo spontaneous dissection and a diffuse, distal-LAD 20% de novo spontaneous dissection with TIMI grade 3 and 2 flow, respectively. A repeat angiogram two days later showed improved coronary artery flow and deemed a low-risk lesion with stable patient hemodynamics; no intervention followed. The patient was treated conservatively with DAPT and discharged home with an outpatient Cardiology follow-up. A plan to have further imaging in 4 weeks to assess hematoma resolution was made. Conclusions: This case demonstrates an atypical presentation of SCAD in a very low-risk patient, given his sex, age, and clinical presentation of nonspecific chest pain. This case highlights the importance of high clinical suspicion for SCAD regardless of ACS risk profile in a patient presenting with chest pain.

Abstract 12259: Recurrent Coronary Artery Dissection in Patient With Systemic Medium-Sized Vessel Vasculitis

Introduction: Universal definition of myocardial infarction (MI) categorizes spontaneous coronary artery dissection (SCAD) as Type 2 ischemia from non-atherothrombotic obstruction. SCAD is rare but growing evidence suggests it is more common than previously understood. Overlap in clinical presentation with Type 1 MI makes invasive coronary angiography (ICA) the gold standard for diagnosis. Here we present a patient with polyarteritis nodosa (PAN) and the sequelae of coronary artery aneurysms and dissections visualized by ICA and further characterized by noninvasive coronary computed tomography angiography (CCTA). Case Report: A 37-year-old man with smoking and hypertension history presented with acute chest pain that felt similar to when he was diagnosed with SCAD of the first diagonal branch one year prior by ICA. Workup then included elevated inflammatory markers and further imaging demonstrating ectatic and beaded-appearing major intra-abdominal and vertebral arteries consistent with PAN. He completed outpatient cyclophosphamide and continued on chronic oral steroids.The catheterization lab was activated on this presentation for ST segment elevations on initial ECG concerning for an inferior MI. Here the distal branches of the right coronary artery (RCA) had new aneurysms and long stenoses with severe luminal narrowing and intramural hematoma consistent with Type 2 SCAD. The culprit lesions had normal TIMI grade 3 flow so were not revascularized. CCTA further characterized the filling defect and RCA false lumen as Type 1 SCAD. Echocardiogram demonstrated a new wall motion dysfunction in correlative distribution. He was optimized on medical therapy including continued dual antiplatelet agents and steroids. Discussion: This patient’s case lends itself to the hypothesis that his PAN manifested ectatic changes to the coronary vasculature from inflammation that predisposed him to recurrent dissection. Therefore, it is reasonable to initiate a vasculitis workup following discovery of coronary artery ectasia and/or dissection. CCTA may even be an effective tool for diagnosis and surveillance of such disease in the right patient and as a means to avoid invasive testing risks.

Clinical Case 31—Active gastrointestinal bleeding during STEMI: a management dilemma

Abstract A man in his 40s presented to the emergency department with chest pain for 8 hours. ECG showed an anterior wall ST-segment elevation myocardial infarction (MI). He received a loading dose of both aspirin and ticagrelor. Coronary angiography demonstrated occlusion of the proximal left anterior descending artery, and primary percutaneous coronary intervention (PCI) with one drug-eluting stent was performed. The patient also presented melena for 5 days. At admission, his hemoglobin was 6.3 g/dL and he was stable. He received a blood transfusion and was started on IV pantoprazole. Endoscopic study was postponed due to concerns related to performing such exam in the setting of a recent MI. The day after PCI, the patient presented major bleeding and hypotension, leading to interruption of the P2Y12 inhibitor. On day 3 of hospitalization, while on single antiplatelet therapy with aspirin, the patient presented new onset of chest pain. He was diagnosed with subacute stent thrombosis (type 4b MI), and thrombus aspiration and balloon angioplasty were performed (Figure 1A, and B). Dual antiplatelet therapy was immediately restarted. Echocardiography revealed worsened left ventricular disfunction (LVEF of 20%). Endoscopy showed tears in the esophagogastric junction (Mallory-Weiss syndrome). This case challenged clinical decision-making, especially the antithrombotic strategy after primary PCI in a patient with major bleeding. Learning points Management of a bleeding patient with acute MI should be individualized. The decision to withhold antithrombotic treatment should weigh the risks related to ongoing bleeding and stent thrombosis. Early endoscopy for acute gastrointestinal bleed in recent MI appears to be a safe procedure for hemorrhage control, although evidence is lacking. Figure 1 Coronary angiography. A—Total occlusion with in-stent thrombus in the proximal left anterior descending artery. B—After thrombus aspiration and angioplasty with paclitaxel-coated balloon of stent thrombosis in the proximal left anterior descending artery, remaining a residual lesion of 50–70%, and distal flow TIMI grade 3.

The Association Between Hematologic Indices with TIMI Flow in STEMI Patients who Undergo Primary Percutaneous Coronary Intervention.

The Primary Percutaneous Coronary Intervention (PPCI) is the preferred therapeutic strategy for patients who experienced ST-Elevation Myocardial Infarction (STEMI). We aimed to evaluate the association of hematological indices, including hemoglobin level, platelets, White Blood Cells (WBCs) count, and MPV before PPCI with the TIMI grade flow after PPCI. STEMI patients who experienced PPCI were included in the present retrospective crosssectional study. Then participants were divided into three groups based on their post-procedural TIMI flow grades. Demographic data and hematologic indices of patients before PPCI were collected and their association with the TIMI grade flow after PPCI was evaluated. To compare the quantitative and qualitative variables, chi-square and t-tests were performed, respectively. We found that elevated levels of hemoglobin and decreased levels of MPV had a significant association with an advanced grade of TIMI flow. Interestingly, in the normal range, there was a significant association between higher platelet count and TIMI-flow grade 1. Besides, TIMI flow grades 2 and 3 had a significant association with low and moderate platelets count, respectively. In conclusion, evaluating MPV, platelets, and hemoglobin levels before PPCI as easy and accessible parameters may be able to identify high-risk STEMI patients undergoing PPCI.

Outcomes of Transradial Approach in Terms of Procedural Failure, in Patients Undergoing Percutaneous Coronary Intervention

Objective: To evaluate the outcomes of transradial approach in terms of procedural failure in patients undergoing percutaneous coronary intervention. Methods: We have enrolled a total of 276 patients who consented for percutaneous coronary intervention through trans-radial approach at National Institute of Cardiovascular diseases, Karachi. Baseline and clinical data were collected in a structured questionnaire. Patients were assessed at the end of completion of PCI for the achievement of TIMI grade 3 flow by angiography under the supervision of experienced consultant having &gt;5 years' experience of intervention. All the data entered and analysed using SPSS version 22.0. Results: Overall mean age of study subjects was 44.86±12.22 years, with range of 52 (18–70) years and among them 194 (70.28%) were males and 82 (29.71%) were females. The overall mean fluoro time was 10.95±4.83 minutes, with range of 22.1 (3.4–25.5) minutes. Our study's findings have shown no significant association of procedure failure was found with respect to gender, age, CRF, smoking, and obesity, p value &lt;0.05. Significant association of procedure failure was observed in patients with hypertension, diabetes mellitus, family history of ischemic heart disease, hyperlipidemia and fluoro time &gt;10 minutes. Conclusion: Transradial approach becomes the primary choice of vascular access for PCI. The transradial approach eliminates access site complications after PCI. Thus, patients discharge from hospital within 48 hours post-procedure and can mobilize within few hours post-procedure. Keywords: Percutaneous Coronary Intervention, Trans-radial approach, Access outcome, Ischemic heart disease, Pakistan

Impact of Early Successful Primary Percutaneous Coronary Intervention on Left Ventricular Systolic Function in ST Elevation Myocardial Infarction Patients

Background: Treatment delay is considered to be one of the important predictors of survival in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated the impact of early successful PPCI for STEMI patients on left ventricular ejection fraction.&#x0D; Methodology: This prospective study was carried out on 50 patients having STEMI undergoing PPCI in NICVD Karachi. Patients were divided into two groups, Group A, early presenter, patients received treatment with PPCI within six hours of the onset of symptoms, and group B, late presenter, patients received treatment after six hours up to twenty-four hours of the onset of symptoms.&#x0D; Results: Group A patients showed promising results, having achieved TIMI grade III flow in 100%, whereas 85% of patients achieved TIMI grade III flow in group B (P = 0.02). There was a statistical difference between the two groups. Using Independent sample T-Test Group A patients showed improved LVEF as compared to Group B (at presentation 45.49±3.99% vs. 35.25±3.85%; P = 0.001 and at 3 months follow up 55.66±0.92% vs. 45.75±1.44%; P = 0.001).&#x0D; Conclusion: Early PPCI treatment of STEMI patients can lead to improved TIMI grade flow and LVEF. Efforts must be made to shorten the delay in reperfusion therapy.

Outcome of Intracoronary Tirofiban administration at Primary Percutaneous Coronary Intervention in St-Elevation Myocardial Infarction Patients

Background: ST-elevation myocardial infarction results from obstruction of coronary flow due to intracoronary thrombus formation. Primary PCI is the gold standard and class-I indication for revascularization following STEMI. Investigators in this study aimed to evaluate the TIMI flow and myocardial blush grade after intracoronary Tirofiban administration in patients with STEMI during the primary percutaneous coronary intervention (PPCI) and its outcome.&#x0D; Methodology: This Cohort study was conducted at Cardiology Department, Niazi Medical &amp; Dental College, Sargodha, after getting informed consent from patients with STEMI. Primary PCI was done in these patients, and two groups were formed. Tirofiban and Non-tirofiban group on basis of Tirofiban administration. Variables included TIMI Grade flow, myocardial blush, major bleeding, minor bleeding, hematoma, MACE, and mortality. P&lt;0.05 was considered statistically significant.&#x0D; Results: The mean age of the study groups was 41.64 ± 12.30 years, with 74% (N=250) males. It was seen that 39 (31.2%) vs 41 (32.8%) with p-value of 0.786 were hypertensive, 28 (22.4%) vs 34 (27.2%) diabetic were having p-value of 0.380 whereas 34 (27.2%) vs 37 (29.6%) with p-value of 0.674 were smokers. TIMI flow grades in both groups were not similar and showed significant differences, indicating that both groups were independent, with a p-value &lt;0.05. The myocardial blush grade was compared in the two groups and the results showed that the score in both the groups was not similar, having significant differences as the p-value was 0.001; major bleeding compared with minor showed statistical insignificance, which indicated that there is a relationship between the two groups. (p-value=0.625 &amp; 0.705 respectively).&#x0D; Conclusion: Administration of intracoronary Tirofiban was associated with superior clinical prognosis in terms of TIMI flow and myocardial blush grades compared with the other group at primary PCI.

Rate and Determinants of Slow Flow / No-Reflow in Patients Undergoing Primary Percutaneous Coronary Intervention at Sandaman Provincial Hospital Quetta

Objective: We investigated the rate of slow/no flow during percutaneous coronary intervention, the clinical and angiographical predictor and the immediate hemodynamic role of slow / no flow. Material &amp; Method: The cross-sectional study was done at Sandaman Provincial Hospital, the Loralai Medical Collage Loralai, Bolan University of Medical and Health Sciences Quetta for six months from 1st July, 2021 to 31st December, 2021. We included ST-elevation myocardial infarction patients who got primary percutaneous coronary intervention (PCI). Patient information, including demographic and clinical data was collected. In this study, thrombolysis in myocardial infarction was used to determine the antegrade flow. There was an evaluation of the existence, predictors, and consequences of slow/no flow in the patients. SPSS 21 was used for data analysis. Results: Among the 300 patients, 283 (80.9%) were males. There were 54 (18.0%) patients who had angiographic slow/no flow during the procedure. TIMI grades were 0 in 13 (4.33%), 1 in 16 (5.33%), and 2 in 25 (8.33%) patients in these affected groups in the study. Smoking status was significantly different between slow and no flow (p=0.023). We found significant associations between prior MI, nonappearance of pre-infarction anginal symptoms, and any cerebrovascular disease with slow/no blood flow (p&lt;0.05). The class III or IV Killip score was significantly higher in the slow/low flow group than the normal-flow group (p&lt;0.05). Intracoronary adenosine and epinephrine were the most often used medications for pharmacological therapy of no/slow flow. The hemodynamic instability of two of the patients (3.70%) of the ventricular tachycardia treatment (VT) cases led to their deaths, while the stability of two (3.70%) of the patients’ VTs required pharmaceutical cardioversion. Conclusion: The occurrence of slow/no flow can be predicted with a history and angiographical feature. Keywords: Slow/no flow, Primary PCI, Angiographical predictors, Hemodynamics’.

Morphine Use in ST-Elevation Myocardial Infarction With Downstream P2Y12 Receptor Blockers-Insight From Observational Study.

Morphine use for patients presenting with NSTE-ACS is associated with excess mortality. However, the role of morphine in STE-ACS is ill characterized. We have recently confirmed direct prothrombotic effect of morphine using murine models. We sought to explore whether morphine use in STE-ACS patients, used to be scheduled for downstream P2Y12 blockers, is negatively associated with procedural and clinical outcomes. A single-center, observational retrospective analysis enrolling 130 non-randomized stable patients sustaining STE-ACS as their first manifestation of coronary disease, who presented between December 2010 and June 2013. All were managed by early invasive approach. Of study patients, 55 were treated by morphine, and 75 were not. All were administered downstream P2Y12 blockers according to an already abandoned local policy. Outcomes evaluated included TIMI grade flow, thrombus burden, ST-segment resolution, myocardial function by echocardiography, and cardiovascular death. Morphine administration was associated with a significantly higher incidence of impaired final TIMI grade flow (TIMI < 3, 40% vs 4%, P < .05), lower incidence of ST-segment resolution >70% (40.7% vs 76.5%, P < .05), and a higher incidence of moderate or severe systolic dysfunction (48.1% vs 29.1%, P < .05) compared with morphine naive patients. Interestingly, the overall mortality rate was higher in the morphine-treated group (18% vs 5.3%, P < .05). Morphine administration combined with the downstream P2Y12 blockers practice signify a group with a higher occurrence of impaired myocardial reperfusion and cardiovascular death despite established on-time primary angioplasty.

Giant left anterior descending artery aneurysm in a patient with active systemic lupus erythematosus: a case report

BackgroundAlthough not common, coronary artery aneurysms (CAAs) can develop to over 8 mm in diameter to become giant CAAs. In the context of systemic lupus erythematosus (SLE), autoantibody- and immune complex-mediated atherosclerosis is believed to be the most prevalent cause of aneurysm.Case presentationWe report the case of a 53-year-old female SLE patient who presented to our hospital with radiating chest pain. Coronary angiography revealed a giant aneurysm in the middle segment of the left anterior descending artery (LAD) and distal subtotal occlusion in the left circumflex artery (LCX). Laboratory testing also identified risk factors such as an abnormal pulmonary enzyme profile, dyslipidemia, and nephritis parameters.To prevent thromboembolism, anticoagulation and antiplatelet therapy were administered. In addition, one stent was implanted at the distal end of the LCX and repeated coronary angiography verified restoration of TIMI grade III flow.The patient was discharged with resolved chest pain. During 6 months of follow-up, the patient is in good health.ConclusionsOur case study, together with 16 recent comparable reports, emphasizes the need for coronary aneurysm screening in SLE patients. It is necessary that thromboembolism, anticoagulation and antiplatelet therapy were administered for CAA.

Abstract 13156: Acute Myocardial Infarction With Biventricular Thrombi Due to Blunt Thoracic Trauma

To our knowledge, this is the first ever reported case of biventricular thrombi with acutemyocardial infarction following blunt thoracic wall trauma. We present a case of a man who presented with non-ST segment elevation myocardial infarction with left anterior descending artery (LAD) occlusion and biventricular thrombi after a blunt thoracic wall trauma. Clinical Vignette: A 56-year-old man with past medical history of diabetes mellitus and hypothyroidism presented to our ED with dizziness after motor vehicle collision. Initial workup revealed biventricular thrombi, pulmonary embolus, and dural sinus thrombosis. 2D echocardiogram showed decreased systolic function with ejection fraction of 15% and enlargement of both ventricles with biventricular thrombi. Serial troponin I levels consistently elevated from 0.3 to 0.6. After initiating cangrelor and heparin infusion, patient underwent coronary angiography which revealed LAD occlusion with a thrombus. Patient then successfully underwent mechanical thrombectomy with restoration of TIMI grade III blood flow. Discussion: Hence, we presented the first ever reported case of biventricular thrombi with LAD occlusion resulting from blunt thoracic wall trauma. While trauma induced musculoskeletal pain may mask symptoms of myocardial infarction, a high index of suspicion for acute coronary syndrome can lead to desirable outcomes in such patients.

CHA2DS2 -VASc score as a predictor for contrast-induced nephropathy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Abstract Background Contrast induced nephropathy (CIN) is one of the most important complications of PCI, resulting in increased medical resources, longer hospital stay and higher mortality so it is important to detect early high risk patients for CIN and provide them with preventive measures. In recent years, several studies have demonstrated an association of CHA2DS2-VASc score with cardiovascular prognosis and adverse outcomes in different populations including heart failure, SCAD and ACS beyond the original AF field. The predictive value of the CHA2DS2-VASc score on CIN still remains unclear although all of the components of the CHA2DS2-VASc score are important risk factors for CIN. For this reason, the present study was designed to evaluate the predictive value of preprocedural CHA2DS2-VASc score on the development of CIN in patients with ACS who underwent PCI. Objective To assess the predictive value of the CHA2DS2-VASc Score for contrast induced nephropathy among acute coronary syndrome patients who underwent percutaneous coronary intervention. Material and methods This study is a prospective study conducted over 300 patients with myocardial infarction underwent primary coronary intervention. It took place from February 2020 till September 2020. We analyzed patient's demographic data, clinical data, laboratory data, angiographic data and CHADSVASC score and followed up patients daily for 72 hour after PCI for development of CIN then compared these data in CIN versus non CIN patients trying to find out which of these factors can predict occurrence of CIN and find CHADSVASC score cutoff value for prediction of CIN. Results CIN was developed in 89 patients. A significant relationship existed between CIN and female gender, DM, HTN, door to needle time, killip class above one, contrast volume (p&amp;lt;0.000), previous intervention using contrast (p&amp;lt;0.001), anemia (p&amp;lt;0.014), duration of procedure (p&amp;lt;0.074) and number of coronary vessels affected (p&amp;lt;0.031). However, non-significant relationship existed between CIN and Stroke, TIA, previous thromboembolism (p&amp;lt;0.446), ejection fraction (p&amp;lt;0.155), culprit vessel (p&amp;lt;0.317), TIMI grade (p&amp;lt;0.278) and antiplatelet type (p&amp;lt;0.934). Receiver operating characteristic curve analysis showed good predictive value of CHA2DS2-VASc score for CIN (area under the curve 0.801, sensitivity 69.66% and specificity 80.75%). Patients with a CHA2DS2-VASc score cutoff value ≥4 had a higher liability for CIN (p&amp;lt;0.000). Conclusion CHA2DS2-VASc score is a simple bedside risk score for preprocedure CIN risk stratification among ACS patients who underwent primary PCI. Funding Acknowledgement Type of funding sources: None.

CHA2 DS2 -VASc score as a predictor for contrast-induced nephropathy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Abstract Background Contrast induced nephropathy (CIN) is one of the most important complications of PCI. It is a common cause of acute renal failure following invasive procedures, resulting in increased medical resources, longer hospital stay, and higher mortality so it is important to detect early high risk patients for CIN and provide them with preventive measures. In recent years, several studies have demonstrated an association of CHA2DS2-VASc score with cardiovascular prognosis and adverse outcomes in different populations including heart failure, SCAD and ACS beyond the original AF field. The predictive value of the CHA2DS2-VASc score on CIN still remains unclear although all of the components of the CHA2DS2-VASc score are important risk factors for CIN. For this reason, the present study was designed to evaluate the predictive value of preprocedural CHA2DS2-VASc score on the development of CIN in patients with ACS who underwent PCI. Objective To assess the predictive value of the CHA2DS2-VASc Score for contrast induced nephropathy among acute coronary syndrome patients who underwent percutaneous coronary intervention. Material and Methods This study is a prospective study conducted over 300 patients with myocardial infarction who presented at ain shams university hospitals for primary coronary intervention. It took place from February 2019 till September 2019. Results From the study population collected (n = 300), 25.7% of which were females (n = 77), statistically significant relation was found between CIN and CHA2DS2-VASc score. (P value 0.000). A significant relationship existed between CIN and CHA2DS2-VASc score more than 3, and each of: age, female gender, DM, HTN, door to needle time, ACS type (NSTEMI) and killip class above one. (P values 0.000), Patients with previous intervention using contrast (P value = 0.001), anemia (P value 0.014) (p value = 0.000) and contrast volume (p value = 0.002) and number of coronary vessels affected (p value = 0.031). However, non-significant relationship could be concluded between CIN and each of Stroke, TIA and previous thromboembolism (P value = 0.446), ejection fraction (P value = 0.155), Time of procedure (p value = 0.131), culprit vessel (p value = 0.317), type of STEMI (p value = 0.140), Revascularization of culprit vessel (p value = 0.143), TIMI grade (p value = 0.278) and antiplatelet type. (P value 0.934) Conclusion CHA2DS2-VASc score is a simple risk score for bedside, preprocedure CIN risk stratification among ACS patients who underwent primary PCI.

Safety and efficacy of dedicated guidewire, microcatheter, and guide catheter extension technologies for chronic total coronary occlusion revascularization: Primary results of the Teleflex Chronic Total Occlusion Study.

Description of procedural outcomes using contemporary techniques that apply specialized coronary guidewires, microcatheters, and guide catheter extensions designed for chronic total occlusion (CTO) percutaneous revascularization is limited. A prospective, multicenter, single-arm study was conducted to evaluate procedural and in-hospital outcomes among 150 patients undergoing attempted CTO revascularization utilizing specialized guidewires, microcatheters and guide extensions. The primary endpoint was defined as successful guidewire recanalization and absence of in-hospital cardiac death, myocardial infarction (MI), or repeat target lesion revascularization (major adverse cardiac events, MACE). The prevalence of diabetes was 32.7%; prior MI, 48.0%; and previous bypass surgery, 32.7%. Average (mean ± standard deviation) CTO length was 46.9 ± 20.5 mm, and mean J-CTO score was 1.9 ± 0.9. Combined radial and femoral arterial access was performed in 50.0% of cases. Device utilization included: support microcatheter, 100%; guide catheter extension, 64.0%; and mean number of study guidewires/procedure was 4.8 ± 2.6. Overall, procedural success was achieved in 75.3% of patients. The rate of successful guidewire recanalization was 94.7%, and in-hospital MACE was 19.3%. Achievement of TIMI grade 2 or 3 flow was observed in 93.3% of patients. Crossing strategies included antegrade (54.0%), retrograde (1.3%) and combined antegrade/retrograde techniques (44.7%). Clinically significant perforation resulting in hemodynamic instability and/or requiring intervention occurred in 16 (10.7%) patients. In a multicenter, prospective registration study, favorable procedural success was achieved despite high lesion complexity using antegrade and retrograde guidewire maneuvers and with acceptable safety, yet with comparably higher risk than conventional non-CTO PCI.

The recanalization after thrombolysis as surrogate for clinical outcomes in patients with ST-segment elevation acute myocardial infarction: A systematic review and meta-regression analysis of data from randomized controlled trials.

Thrombolytic therapy has been known to be effective in reducing clinical outcomes and increasing recanalization rate among patients with ST-segment elevation acute myocardial infarction (STEMI). However, whether post-thrombolysis recanalization could be used as a surrogate for clinical outcomes is unknown. We systematically searched PubMed, EMBASE and the Cochrane Library database to identify randomized controlled trials (RCT) that examined effects of thrombolytic agents in STEMI. Recanalization was defined as TIMI grade 2 or 3 flow. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included in-hospital and 30-day recurrent myocardial infarction (re-MI), composite of death and re-MI, major bleeding and all bleeding. Random-effects meta-regression was used for analysis. We identified 111 eligible study arms and 52 eligible comparisons from 58 RCTs involving 16 536 patients. Our analyses showed that among study arms recanalization rate was significantly inversely associated with the incidence of in-hospital all-cause mortality (β: -0.07, 95% confidence interval [CI]: -0.13 to -0.02), re-MI (β: -0.09, 95%CI: -0.18 to -0.01) and the composite of death and re-MI (β: -0.17, 95%CI: -0.28 to -0.05), and positively associated with in-hospital all bleeding but not with major bleeding. Among paired comparisons, the difference in recanalization rate was associated with the corresponding difference in incidence of in-hospital all-cause mortality (β: -0.15, 95%CI: -0.28 to -0.01) but the relationship was not significant for any other outcome. Pooled evidence from RCTs suggest the potential use of recanalization as a surrogate for clinical outcomes in evaluating the efficacy of thrombolysis among patients with STEMI.

Fifteen-Year Mortality and Cardiac, Thrombotic, and Bleeding Events in Survivors of ST-Elevation Myocardial Infarction

BackgroundAlthough short-term mortality in ST-elevation myocardial infarction (STEMI) has improved, data is limited regarding very long-term mortality and concomitant clinical events in STEMI survivors who undergo primary percutaneous coronary intervention (p-PCI). This study aimed to evaluate these parameters at 15 years and to determine the predictors of 15-year mortality in these patients. MethodsThe study endpoints were all-cause mortality and cardiac mortality at 15 years. Independent predictors of all-cause mortality were also analyzed. Furthermore, each thrombotic and bleeding event was evaluated. ResultsBetween January 2004 and December 2006, 260 STEMI survivors who underwent p-PCI (median follow-up period: 3970 days) were evaluated from the Ogaki Municipal hospital registry. The rates of all-cause mortality (cardiac mortality) at 5, 10, and 15 years were 12.1% (4.9%), 23.4% (9.5%), and 34.9% (12.4%), respectively. The cumulative incidences of recurrent myocardial infarction, target vessel revascularization, ischemic stroke, hemorrhagic bleeding, and gastric bleeding at 15 years were 11.3%, 43.6%, 14.3%, 6.9%, and 10.9%, respectively. Cox regression analysis showed that age ≥ 75 years [adjusted hazard ratio (aHR), 7.074, p < 0.001], chronic kidney disease (aHR, 2.320, p = 0.001), left ventricular ejection fraction <40% (aHR, 2.930, p = 0.001), Killip class ≥II at admission (aHR, 2.639, p = 0.003), untreated chronic total occlusion (aHR, 2.090, p = 0.042), and final TIMI grade ≤ 2 (aHR, 1.736, p = 0.048) were independent predictors of all-cause mortality. ConclusionThis study demonstrated that all-cause and cardiac mortality at 15 years were 34.9% and 12.4%, respectively, in all-comers STEMI survivors after p-PCI, indicating that STEMI survivors might have a benign prognosis.

Coronary angioplasty and COVID-19: are heparin requirements and thrombotic complications increasing?

Funding AcknowledgementsType of funding sources: None.BackgroundCovid-19 infection is associated with coagulopathy and possible heparin resistance, raising concerns that routine heparin during percutaneous coronary intervention (PCI) is failing to achieve adequate anticoagulation. We examined heparin requirements and efficacy in patients treated by PCI before and after the first reported UK case of Covid-19 (January 31st 2020).MethodsWe retrospectively compared heparin dose, Activated Clotting Time (ACT) and coronary flow (TIMI grade) for PCI procedures at a London cardiac centre in the 3 months before the UK pandemic and the three months afterwards. Testing for COVID was not routinely performed. Pre-specified analyses in patients with STEMI, NSTEMI and Stable angina were undertaken.ResultsOf 1227 PCI procedures performed over the period of observation, 690 were pre-pandemic and 537 were afterwards. Overall median heparin dose per case was 11000units versus 11500units (p = 0.137) and maximum ACTs were 291s versus 305s, respectively (p = 0.135). Pre-PCI TIMI 3 flow was lower during the pandemic than before (60% v 65%, p = 0.005) but Post-PCI flow was similar (96% versus 96%, p = 0.839). There were no statistically significant differences in heparin dose or achieved ACT among patients with STEMI, NSTEMI or Stable presentations.ConclusionIn spite of the increasing evidence that COVID-19 infection causes thrombosis, it appears that standard heparin management during PCI is sufficient to achieve effective anticoagulation and avoid peri-procedural thrombotic complications. Group 1 Pre PandemicGroup 2 PandemicP valueNumber of doses given3 (3 to 4)3 (3 to 4)0.952Total Heparin dose (units)11000 (8000 to 14000)11500 (9000 to 14000)0.137Number of ACTs measured2 (1 to 2)2 (1 to 2)0.194First ACT (seconds)240 (199 to 318)248 (206 to 326)0.256Maximum ACT (seconds)291 (230 to 368)305 (239 to 369)0.135Heparin dose and Activated Clotting Times (ACT) in patients undergoing PCI before Covid-19 pandemic (Group 1) and during pandemic (Group 2); median and interquartile ranges Figure. Clinical Presentation