Feasibility and applicability of computer‐assisted myocardial blush quantification after primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction

Objectives : The aim of the study was to evaluate whether the “Quantitative Blush Evaluator” (QuBE) score is associated with measures of myocardial reperfusion in patients with ST‐segment elevation myocardial infarction (STEMI) treated in two hospitals with 24/7 coronary intervention facilities. Background : QuBE is an open source computer program to quantify myocardial perfusion. Although QuBE has shown to be practical and feasible in the patients enrolled in the Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS), QuBE has not yet been verified on reperfusion outcomes of primary percutaneous coronary intervention (PCI) patients treated in other catheterization laboratories. Methods : Core lab adjudicated angiographic outcomes and QuBE values were assessed on angiograms of patients who were enrolled in the PRoximal Embolic Protection in Acute myocardial infarction and Resolution of ST‐Elevation (PREPARE) trial. ST‐segment resolution immediately after PCI measured by continuous ST Holter monitoring was calculated by a blinded core lab. Results : The QuBE score could be assessed on 229 of the 284 angiograms (81%) and was significantly associated with visually assessed myocardial blush grade (P < 0.0001). Patients with improved postprocedural Thrombolysis in Myocardial Infarction‐graded flow, myocardial blush grade, ST‐segment resolution immediately after PCI, or a small infarct size measured by peak CK‐MB had a significant better QuBE score. Conclusions : QuBE is feasible and applicable at angiograms of patients with STEMI recorded at other catheterization laboratories and is associated with measures of myocardial reperfusion. © 2010 Wiley‐Liss, Inc.     

Impact of the prehospital ECG on door‐to‐balloon time in ST elevation myocardial infarction

Aim : To compare the results of percutaneous mitral valvuloplasty (BMV) for mitral restenosis in post‐BMV versus postclosed mitral valvotomy (CMV) patients. Methods and Results : Ninety‐two patients who underwent BMV for mitral restenosis were followed up prospectively. Of these, 28 patients had undergone previous percutaneous mitral valvuloplasty (PRIOR BMV) and 64 patients had undergone previous closed mitral valvotomy (PRIOR CMV). BMV for mitral restenosis was a success in 59% patients (57.1% PRIOR BMV, 59.3% PRIOR CMV, P = 1.0). Incidence of severe mitral regurgitation was 3.25%, all in the PRIOR CMV group. In univariate analysis, the major predictor of successful BMV for mitral restenosis was Wilkins score (P = 0.004). At a follow up of 3.47 + 2.07 years, mitral valve area was similar between groups (1.45 ± 0.22, 1.46 ± 0.26, P = 0.35). The combined end points of mitral valve replacement (MVR), need for rerepeat BMV for mitral restenosis or death was higher in the PRIOR CMV group (31.2% PRIOR CMV, 7.1% PRIOR BMV, P = 0.027). Event‐free survival at follow up was lower in the PRIOR CMV group (69% PRIOR CMV, 92.8% PRIOR BMV) mainly due to the higher need for MVR (11 vs. 0 patients, P = 0.03). Conclusions : In conclusion, following BMV for mitral restenosis, patients with PRIOR BMV are found to have lesser event rates on follow‐up compared to patients with PRIOR CMV, though procedural success rates are similar. © 2010 Wiley‐Liss, Inc.     

Prognostic impact of intensive statin therapy on N‐terminal pro‐BNP level in non‐ST‐segment elevation acute myocardial infarction patients

Objective

This study explored the impact of intensive daily dosing of atorvastatin on in‐hospital N‐terminal pro‐B‐type natriuretic peptide level, left ventricular systolic function and incidence of major adverse cardiac events in non‐ST‐segment elevation myocardial infarction patients.

Background

Several studies showed that early initiation of statin therapy in acute coronary syndrome patients has a favorable prognostic impact.

Methods

Hundred statin naive patients were prospectively enrolled. Once eligible, patients were randomly assigned to receive either a moderate daily dose that is, 20 mg (Group A) or an intensified daily dose that is, 80 mg (Group B) of atorvastatin, in addition to an equally divided loading dose given 24 and 12 h before coronary angiography (80 mg each). N‐terminal pro‐B‐type natriuretic peptide levels were recorded before and after coronary intervention. Collected data after 3 months included; N‐terminal pro‐B‐type natriuretic peptide levels, left ventricle systolic function and major adverse cardiac events.

Results

Mean age of the study cohort was 55 ± 10 years, 68% being males. There was no significant difference between both groups concerning procedural data. Group B patients showed a significantly lower N‐terminal pro‐B‐type natriuretic peptide levels at both sampling occasions, i.e., after coronary intervention and 3 months later (P < 0.001). After 3 months, the same group showed higher left ventricle ejection fraction (P < 0.05), with no significant difference between both groups regarding incidence of major adverse cardiac events.

Conclusion

Intensive atorvastatin therapy in non‐ST‐segment elevation myocardial infarction patients undergoing percutaneous coronary intervention is associated with; lower in‐hospital N‐terminal pro BNP level and higher LVEF after 3 months.

     

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Clinical guidelines for the treatment of patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long‐term mortality risk than patients with ST‐segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the “treatment‐risk paradox”). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four “P” factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long‐term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.     

The impact of successful revascularization of coronary chronic total occlusions on long‐term clinical outcomes in patients with non‐ST‐segment elevation myocardial infarction

Objectives

The purpose of this study was to assess the long‐term clinical impact of revascularization of coronary concomitant coronary chronic total occlusion (CTO) in patients with Non‐ST‐segment elevation myocardial infarction (NSTEMI).

Background

CTO is associated with poorer prognosis in patients with NSTEMI. The evidence of revascularization of CTO in patients with NSTEMI is still conflicting.

Methods

Consecutive patients with NSTEMI and CTO who underwent percutaneous coronary intervention (PCI) within 72 h of admission from 2006 to 2015 were retrospectively recruited and analyzed. A total of 967 patients underwent PCI for NSTEMI. Among them, 106 (11%) patients had concomitant CTO and were recruited for analysis. CTO lesions were revascularized successfully in 67 (63.2%) patients (successful CTO PCI group), while the CTO in the remaining 39 patients were either not attempted or failed (No/failed CTO PCI group).

Results

The 30‐day cardiac death and major adverse cardiac events (MACE) were significantly lower in the successful CTO PCI group (both cardiac death and MACE were 3% vs 30%, P < 0.001, respectively). A landmark analysis set at 30th day for 30‐day survivals was performed. After a mean of 2.5‐year follow‐up, the long‐term cardiac death was still significantly lower (16.9% vs 42.3%, P < 0.001), whereas the MACE showed a trend toward lower incidence (26.2% vs 40.7%, P = 0.051) in the successful CTO PCI group. In multivariate Cox regression analysis, successful revascularization of CTO is an independent protective predictor for long‐term cardiac death (HR 0.310, 95% CI, 0.109‐0.881, P = 0.028) in all population and in propensity‐score matched cohort (P = 0.007).

Conclusions

Successful revascularization of CTO was associated with reduced risk of long‐term cardiac death in patients with NSTEMI and concomitant CTO.

     

Long‐term outcomes in patients with restrictive filling following ST‐segment elevation myocardial infarction

This study evaluated the effect of restrictive filling pattern (RFP) on 5‐year outcomes in patients following ST‐segment elevation myocardial infarction (STEMI). A hundred STEMI patients treated either by rescue or primary percutaneous coronary intervention with an echocardiogram performed within 6 weeks of STEMI comprised the study group. Creatinine kinase (CK) and left ventricular ejection fraction were independent determinants of RFP, and RFP was an independent predictor of cardiac and all‐cause mortality at median follow up of 5 years.