Left circumflex artery-related myocardial infarction: Does ST elevation matter? Results from the Euro Heart Survey PCI registry

Background/objectives

Little is known about angiographic and clinical differences in patients presenting with left circumflex artery (LCX)-related ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI). We sought to determine the clinical significance of ST elevations in patients with LCX-related myocardial infarction.

Methods and results

Between 2005 and 2008 10,503 consecutive patients with acute STEMI and NSTEMI undergoing percutaneous coronary intervention (PCI) were prospectively enrolled into the Euro Heart Survey PCI-Registry. For the present analysis patients with LCX-related STEMI (n = 1100, 54.7%) were compared to those with LCX-related NSTEMI (n = 910, 45.3%). NSTEMI-patients were older, more often female and had a higher incidence of prior cardiac events. Patients with STEMI more frequently presented with shock (8.0 versus 3.9%, P < 0.001) or had been resuscitated (8.5 versus 2.7%, P < 0.0001). TIMI 0–1 before PCI was much more often found among those with STEMI (58.2 versus 25.1%, P < 0.0001). In the univariate analysis there were no significant differences in hospital mortality (STEMI: 4.8%, NSTEMI: 3.5%, P = 0.17), however after adjustment for age, female gender, diabetes and chronic renal failure hospital mortality was significantly higher in STEMI patients (odds ratio 1.71, 95%-CI 1.08–2.72, P < 0.05).

Conclusions

Over 50% of the patients with LCX-related myocardial infarction treated with PCI had ST elevations in the initial electrocardiogram. STEMIs were more often associated with total vessel occlusions or haemodynamic instability. In-hospital mortality was significantly higher in patients with LCX-related STEMI.     

Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease

Background and purpose

We aimed to study the prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction (STEMI) and non-significant coronary artery disease (CAD).

Methods

From January to October 2012 we consecutively included patients admitted with suspected STEMI and non-significant CAD (coronary artery stenosis diameter < 50%). Patients were diagnosed with acute cardiac disorder in the presence of elevated cardiac biomarkers (troponin T > 50 ng/l or creatine kinase MB > 4 μg/l) or dynamic ECG changes (ST-segment changes or T-wave inversion).

Results

Of the 871 patients admitted with suspected STEMI, 11% (n = 95) had non-significant CAD. Of these, 67% (n = 64) had elevated cardiac biomarkers or dynamic ECG changes and were accordingly diagnosed with acute cardiac disorders. In the remaining 33% (n = 31) of patients, cardiac biomarkers were normal and ECG changes remained stationary.

Conclusions

Acute cardiac disorders were diagnosed in two thirds of patients with suspected STEMI and non-significant CAD.     

Impact of increased transmitral gradients after undersized annuloplasty for chronic ischemic mitral regurgitation

Introduction

It is unknown whether drug-eluting stents (DES), in comparison with bare-metal stents (BMS), improve clinical outcomes of ST-elevation myocardial infarction (STEMI) patients with renal insufficiency. We aimed to compare the clinical outcomes of BMS versus DES, as well as sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES), in STEMI patients with renal insufficiency.

Methods

From the Korea Acute Myocardial Infarction Registry, 874 STEMI patients with renal insufficiency (glomerular filtration rate < 60 ml/min) comprising 116 patients with BMS and 758 patients with DES (430 SES and 328 PES) implantation were selected. Major adverse cardiac events (MACE) within 1 year, defined as composite of all-cause mortality, nonfatal myocardial infarction and target lesion revascularization were compared. In addition to multivariate adjusted analysis, propensity analysis for stent choice was performed.

Results

With a median follow-up of 342 days, 116 MACE occurred. MACE was more frequent in the BMS group than in the DES group before (HR [95% CI] = 2.3 [1.3-3.8]) and after propensity score matching (HR [95% CI] = 2.0 [1.0-3.8]). The difference of MACE was mainly driven by a higher rate of target lesion revascularization rate in the BMS group. In comparison between SES and PES, there was no significant difference between the 2 groups in propensity score-matched populations (HR [95% CI] = 0.7 [0.4-1.1]).

Conclusions

In STEMI patients with renal insufficiency, DES implantation exhibits a favorable 1 year clinical outcomes than BMS implantation, however, no difference was found between SES and PES.     

急性冠状动脉综合征患者N末端B型钠尿肽前体和肌钙蛋白Ⅰ水平与冠状动脉病变的关系

目的探讨急性冠状动脉综合征患者血清N末端B型钠尿肽前体(NT-proBNP)和肌钙蛋白I(cTnI)含量与冠状动脉病变程度的关系。方法选择急性冠状动脉综合征患者98例,分为急性ST段抬高心肌梗死(STEMI)组46例,急性非ST段抬高心肌梗死(NSTEMI)组16例,不稳定性心绞痛(UAP)组36例,均于入院时或发病24 h内测定患者血清NT-proBNP、cTnI含量,冠状动脉造影了解冠状动脉病变情况,并行心脏彩色多普勒超声检测,以评估患者的心功能。结果与UAP组比较,STEMI组和NSTEMI组NT-proBNP明显升高;与NSTEMI组比较,STEMI组cTnI明显升高(P<0.05)。NT-proBNP与冠状动脉病变积分呈正相关(r=0.156,P<0.05),与LVEF呈负相关(r=-0.196,P<0.01);cTnI与冠状动脉病变积分呈正相关(r=0.247,P<0.01)。结论急性冠状动脉综合征患者NT-proBNP与cTnI无关,但两者均可反映冠状动脉病变的严重程度。NT-proBNP的高低能反映患者的心功能状态,cTnI则与心功能无关。     

Sex and age specific time patterns and long term time trends of pre-hospital delay of patients presenting with acute ST-segment elevation myocardial infarction

Background

Prompt initiation of treatment after symptom onset of ST-elevation myocardial infarction (STEMI) is a central goal in limiting myocardial damage because of the time-dependent nature of reperfusion therapies. We examined time patterns and long term time trends of pre-hospital delay time (PHDT) of STEMI patients.

Methods

PHDT from 3093 STEMI patients derived from the Augsburg Myocardial Infarction Registry (1985-2004) surviving > 24 h after admission was obtained by a standardized bedside interview. Patients with in-hospital MI (n = 140) and resuscitation (n = 157) were excluded. Linear regression models were used to examine monthly median PHDT and individual PHDT over time.

Results

Female sex was associated with longer PHDT (189 (98-542 quartiles) min vs. 154 (85-497) min; p < 0.0003). Median PHDT in the youngest male subgroup (25-54 years) was 128 (73-458) min and mounted to 205 (107-600) min in the oldest female subgroup (65-74 years). A minority of 12.4% of patients reached hospital within 1 h of delay ranging from 8.7% (in oldest women) to 15.9% (in youngest men).The age-adjusted linear regression model for monthly PHDT revealed no significant change over 20-year time in both sexes. The corresponding average annual percentage change estimates were −0.45 (95% CI: −1.40 to 0.54) for men and −0.08 (95% CI: −1.80 to 1.67) for women. Emergency ambulance use increased over time, however transportation time remained stable.

Conclusions

PHDT in STEMI patients is constantly high over a 20-year observation period. Room for improvement especially in older women was evidenced. Preventive strategies with focused efforts on this subgroup are warranted.     

Growth differentiation factor-15 in Takotsubo cardiomyopathy: Diagnostic and prognostic value

Background

Growth differentiation factor-15 (GDF-15), a stress responsive cytokine, has emerged as a marker of adverse outcome in various cardiovascular diseases. Since GDF-15 has not been evaluated in patients with Takotsubo cardiomyopathy (TTC), the present study sought to investigate the diagnostic and prognostic value in this patient cohort.

Methods

A total of 22 patients presenting with TTC were matched for age and gender with 22 ST-segment elevation myocardial infarction (STEMI) patients. GDF-15 concentrations were measured at admission and 1 day thereafter. The primary clinical endpoint of the TTC cohort was the composite of death, cardiogenic shock, or new congestive heart failure within 6 months.

Results

TTC patients showed significantly higher GDF-15 values on admission compared to patients presenting with STEMI (median 3047 ng/l [interquartile range 2256–7572] versus median 1527 ng/l [interquartile range 1152–2677]; p = 0.002). TTC patients with a biventricular ballooning pattern and patients experiencing major adverse cardiac events during the first 6 months after acute presentation showed significantly higher GDF-15 concentrations on admission (p = 0.008 and p = 0.005, respectively). Biventricular ballooning was identified as a predictor for elevated GDF-15 values on admission (p = 0.03). High GDF-15 levels on admission were the only significant predictor for the combined clinical endpoint in multivariable regression analysis (p = 0.02).

Conclusion

TTC patients showed markedly high, but transient elevation of GDF-15 levels. Biventricular ballooning was associated with particularly high GDF-15 concentrations. Elevated GDF-15 values on admission were a strong predictor of adverse clinical outcome.     

Elevated NT-proBNP levels should be interpreted in elderly patients presenting with dyspnea

Background

B-type natriuretic peptide (BNP) assay is a useful tool in order to diagnose dyspnea due to congestive heart failure (CHF). On the other hand many other diseases could affect BNP levels. The aim of this study was to investigate a group of elderly patients admitted to an Internal Medicine unit because of dyspnea.

Patients and methods

NT-proBNP was assessed in 132 consecutive patients aged 80 ± 6 years because of dyspnea. History data, anthropometric, clinical and biochemical parameters were collected. Renal function was assessed by the CKD-EPI formula. Diagnosis of pulmonary disease such as infections and chronic obstructive disease was considered and was analyzed as a single parameter. Statistical analysis was carried out dividing patients with high NT-proBNP from those with normal NT-proBNP according to the Januzzi cut-off.

Results

NT-proBNP was higher than the normal reference values in 68.7% of patients and its levels increased in the 5 different stages of chronic kidney disease. Subjects with high NT-proBNP had lower haemoglobin levels (11.6 ± 2.1 vs 12.8 ± 1.9 g/dl, p = 0.003), higher prevalence of atrial fibrillation (54.3 vs 25%, p = 0.001), and lower prevalence of pulmonary diseases (29.7 vs 57.5%, p = 0.005). Logistic regression analysis showed that NT-proBNP levels were independently associated with haemoglobin (OR 1.307 95% CI 1.072-1.593, p = 0.008) and pulmonary diseases (OR 3.069 95% CI 1.385-6.801, p = 0.006).

Conclusions

A disease different from CHF appears to affect NT-proBNP plasma levels. Therefore, determination of its levels does not seem to help clinicians in the definition of dyspnea in elderly people with different comorbidities.     

ST段抬高型心肌梗死患者N末端脑利钠肽前体水平及其相关因素分析

目的探讨N末端脑利钠肽前体(NT-proBNP)在ST段抬高型心肌梗死患者的水平及其相关影响因素。方法入选诊断明确的急性ST段抬高型心肌梗死患者,并对NT-proBNP水平与可能的相关因素如性别、年龄、病史、心肌梗死范围、心房心室大小、冠状动脉病变情况、治疗情况以及肌钙蛋白I峰值等进行分析。结果在70例患者中未发现性别、高血压或糖尿病病史以及心房心室大小影响NT-proBNP水平。前壁心肌梗死或者心肌梗死累及部位更多的患者,NT-proBNP水平较高[累及前壁的心肌梗死(5116.7±2657.3)ng/L比非前壁心肌梗死(1150.5±916.1)ng/L,P=0.002;3部位受累患者(6269.3±3394.9)ng/L比2部位受累患者(4468.6±2259.8)ng/L或1部位受累患者(1282.1±946.4)ng/L,P=0.027]。年龄(r=0.335,P=0.009)和血肌酐水平(r=0.495,P=0.000)与NT-proBNP水平正相关,LVEF与其呈负相关(r=-0.343,P=0.01),差异有统计学意义。罪犯血管为前降支病变也与较高的NT-proBNP水平相关[前降支(4179.1±2728.2)ng/L比右冠状动脉或回旋支(670.7±359.2)ng/L,P=0.011]。接受直接冠心病介入治疗(PCI)者NT-proBNP水平较低[接受直接PCI(2690.8±1459.9)ng/L比未接受直接PCI的患者(6260.0±3191.2)ng/L,P=0.039]。结论 ST段抬高型前壁心肌梗死患者NT-proBNP较高,其升高程度与心电图判断的心肌受累范围相关,接受直接PCI的患者NT-proBNP水平较低。低LVEF与NT-proBNP水平升高的相关性不受年龄和血肌酐水平的影响。     

Age-dependent inequalities in improvements in mortality occur early after acute myocardial infarction in 478,242 patients in the Myocardial Ischaemia National Audit Project (MINAP) registry

Background

Mortality rates after acute myocardial infarction (AMI) have declined, but there is uncertainty regarding the extent of improvements in early mortality in the elderly.

Methods

Mixed-effects regression analysis of 30-day mortality using data from 478,242 patients with AMI at 215 hospitals in England and Wales stratified by STEMI/NSTEMI, sex, and age group. A hospital opportunity-based composite score (OBCS) for aspirin, ACE-inhibitor, statin, β blocker, and referral for cardiac rehabilitation was used as measure of quality of hospital care.

Results

30-day mortality rates (95% CI) fell from 10.7% (10.6 to 10.9%) in 2004/5 to 8.4% (8.3 to 8.6%) in 2008/9. The median (IQR) hospital OBCSs increased over time, 2004/5: 87.3 (7.2), 2006/7: 88.9 (6.3), 2008/9: 90.3 (6.1), P < 0.001, and were similar between age groups (18 to < 65 years, 65 to 79 years, and ≥ 80 years) for STEMI: 89.4 (6.5) vs. 89.4 (6.6), vs. 89.2 (6.5) and NSTEMI: 88.6 (7.3) vs. 88.8 (7.0) vs. 88.9 (7.0), respectively For males, all age groups except patients < 65 years demonstrated a significant decrease in adjusted mortality. For females, only patients ≥ 80 years demonstrated a significant reduction in adjusted mortality. A 1% increase in hospital OBCS was associated with a 1% decrease in 30-day mortality (95% CI: 0.99 to 0.99, P < 0.001).

Conclusion

In England and Wales, for patients with AMI there are age and sex-dependent differences in improvements in 30-day mortality. Whereas young males with AMI have reached an acceptable performance plateau, all other groups are either improving or, more importantly, are yet to demonstrate this.     

Red blood cell and platelet microparticles in myocardial infarction patients treated with primary angioplasty

Background

Red blood cell and platelet microparticles (RBCm and PLTm, respectively) have drawn research attention as to their potential prothrombotic and vasoconstrictive effects in experimental settings. However, the relevance of circulating microparticles in clinical settings is largely undetermined.

Methods

Circulating microparticles were quantified with a flow cytometric method in blood samples from consecutive STEMI patients after primary PCI. A matched cohort of healthy volunteers was used to derive reference values for comparison. STEMI patients were followed for 6 months for a composite clinical endpoint.

Results

Fifty-one STEMI patients (age 59.8 ± 8.8 years) and 50 controls (age 56.2 ± 9.2 years; p = 0.155) were enrolled. RBCm concentration was 18,198 ± 6062/μl in the reference cohort versus 33,740 ± 21,169/μl in STEMI patients (p < 0.001). RBCm count was not correlated to total RBCs (standardized beta 0.018; p = 0.861). PLTm did not differ between groups (17,529 ± 16,292/μl in STEMI patients versus 14,372 ± 6211/μl in controls; p = 0.203). RBCm c-statistic was 0.832 (95% confidence interval 0.720 to 0.944), while PLTm prognostic value was not statistically significant (c-statistic 0.614, 95% confidence interval 0.444 to 0.784). In the multivariate analysis, RBCm concentration was independently associated with the occurrence of the clinical endpoint, after adjustment for age, ejection fraction, serum creatinine and presence of diabetes (adjusted p = 0.034).

Conclusions

The present study demonstrates for the first time that erythrocyte microparticles are elevated in patients with STEMI treated with primary PCI, with levels approximately double those measured in a reference population of healthy volunteers, and their concentrations appear to be positively associated with adverse clinical events.     

A combination of increased Rho kinase activity and N-terminal pro-B-type natriuretic peptide predicts worse cardiovascular outcome in patients with acute coronary syndrome

Background

Recent experimental evidence suggests that the Rho/Rho-kinase (ROCK) system may play an important role in the pathogenesis of acute coronary syndrome (ACS) but there are little clinical data. This study examined if ROCK activity is increased in patients with acute coronary syndrome and if ROCK activity predicts long‐term cardiovascular event.

Method

Blood samples were collected from 188 patients within 12 h after admission for ACS (53% men; aged 70 ± 13) and from 61 control subject. The main outcome measures were all cause mortality, readmission with ACS or congestive heart failure (CHF) from presentation within around 2 years (mean:14.4 ± 7.2 months; range: 0.5 to 26 months).

Results

ROCK activity increased in ST elevation myocardial infarction (STEMI, n = 90) (3.33 ± 0.93), non-STEMI (NSTEMI, n = 68) (3.37 ± 1.04) and unstable angina (UA, n = 30) (2.53 ± 0.59) groups when compared with disease controls (n = 31) (2.06 ± 0.38, all p < 0.001) and healthy controls (n = 30) (1.54 ± 0.43, all p < 0.001). There were 24 deaths, 34 readmissions with ACS and 15 admissions with CHF within 2 years. Patients with a high N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high ROCK activity on admission had a five-fold risk of a cardiovascular event (RR: 5.156; 95% CI: 2.180–12.191) when compared to those with low NT-proBNP and low ROCK activity.

Conclusion

ROCK activity was increased in patients with ACS, particularly in those with myocardial infarction. The combined usage of both ROCK activity and NT-proBNP might identify a subset of ACS patients at particularly high risk.     

通过ROC曲线评估联合检测TnI、hs-CRP和NT-proBNP对老年急性冠状动脉综合征的诊断价值

目的:通过ROC曲线探讨肌钙蛋白I(TnI)、超敏C反应蛋白(hs-CRP)和N末端脑利钠肽前体(NT-proBNP)联合检测在老年急性冠状动脉(冠脉)综合征(ACS)临床诊断中的应用价值。方法:收集不稳定型心绞痛(UA组,60例)、非ST段抬高型心肌梗死(NSTEMI组,61例)、ST段抬高性心肌梗死(STEMI组,59例)患者及健康者(对照组,60例)血清样本,用化学发光免疫法检测TnI,电化学发光免疫法检测NT-proBNP,速率散射免疫比浊法测定hs-CRP;绘制ROC曲线并建立Logistic回归模型,分析各指标单独和联合检测在UA、NSTEMI及STEMI诊断中的作用。结果:除UA组TnI外,ACS 3个组中血清TnI、hs-CRP与NT-proBNP值显著高于对照组(P<0.05);与单独检测相比,3项指标联合检测时,UA组、NSTEMI组和STEMI组ROC曲线下面积(AUC)[(0.858±0.051)、(0.988±0.013)和(0.998±0.004)]最大,灵敏度(57.8%、95.9%和99.1%)和特异度(94.7%、100.0%和100.0%)也最好。结论:联合检测TnI、hs-CRP和NT-proBNP有助于老年ACS中UA的诊断,对NSTEMI与STEMI的灵敏度和特异度也能达到最优化,但对区分NSTEMI和STEMI效果不明显。     

New ST-segment elevation myocardial infarction criteria for left bundle branch block based on QRS area

Background

ECG detection of ST-segment elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) is challenging due to ST deviation from the altered conduction. The purpose of this study was to introduce a new algorithm for STEMI detection in LBBB and compare the performance to three existing algorithms.

Methods

Source data of the study group (143 with acute MI and 239 controls) comes from multiple sources. ECGs were selected by computer interpretation of LBBB. Acute MI reference was hospital discharge diagnosis. Automated measurements came from the Philips DXL algorithm. Three existing algorithms were compared, (1) Sgarbossa criteria, (2) Selvester 10% RS criteria and (3) Smith 25% S-wave criteria. The new algorithm uses an ST threshold based on QRS area. All algorithms share the concordant ST elevation and anterior ST depression criteria from the Sgarbossa score. The difference is in the threshold for discordant ST elevation. The Sgarbossa, Selvester, Smith and Philips discordant ST elevation criteria are (1) ST elevation ≥ 500 μV, (2) ST elevation ≥ 10% of |S|-|R| plus STEMI limits, (3) ST elevation ≥ 25% of the S-wave amplitude and (4) ST elevation ≥ 100 μV + 1050 μV/Ash * QRS area. The Smith S-wave and Philips QRS area criteria were tested using both a single and 2 lead requirement. Algorithm performance was measured by sensitivity, specificity, and positive likelihood ratio (LR +).

Results

Algorithm performance can be organized in bands of similar sensitivity and specificity ranging from Sgarbossa score ≥ 3 with the lowest sensitivity and highest specificity, 13.3% and 97.9%, to the Selvester 10% rule with the highest sensitivity and lower specificity of 30.1% and 93.2%. The Smith S-wave and Philips QRS area algorithms were in the middle band with sensitivity and specificity of (20.3%, 94.9%) and (23.8%, 95.8%) respectively.

Conclusion

As can be seen from the difference between Sgarbossa score ≥ 3 and other algorithms for STEMI in LBBB, a discordant ST elevation criterion improves the sensitivity for detection but also results in a drop in specificity. For applications of automated STEMI detection that require higher sensitivity, the Selvester algorithm is better. For applications that require a low false positive rate such as relying on the algorithm for pre-hospital activation of cardiac catheterization laboratory for urgent PCI, it may be better to use the 2 lead Philips QRS area or Smith 25% S-wave algorithm.     

Reactive protein,plasminogen activator inhibitor type-1 （PAI-1） levels,PAI-1 promoter 4G/5G polymorphism and acute myocardial infarction

Objective To investigate the relationship between CRP, plasminogen activator inhibitor type 1 （PAI-1） levels, PAI-1 gene promoter 4G/5G polymorphism and the type of acute myocardial infarction （ST elevation myocardial infarction, STEMI vs the non-ST elevation Myocardial infarction, NSTEMI）. Methods One hundred seventy-six consecutive patients with AMI were included for the study, of whom 60 had STEMI and 56 had NSTEMI, and 60 adults without cardiovascular and cerebrovascular disease were selected as controls. Blood samples were obtained from patients within 6 h of AMI and the plasma PAI-1, CRP, and the gene polymorphism were measured. Results Plasma levels of PAI- 1 and CRP were higher in AMI groups, compared those in the control group, and plasma levels of PAI-1 were significantly higher in patients with STEMI compared to those with NSTEMI （80.12ng/ml VS.73.01ng/ml, P 〈0.01）, while CRP levels were not significantly different between patient with STEMI and NSTEMI （3.87 ± 0.79 mg/ml VS.4.01 ±0.69mg/ml, P〉0.05）. PAI-1 levels presented a significant correlation with CRP levels in the NSTEMI subjects. However, PAI-1 and CRP levels could explain the lack of a significant relationship between them in control and STEMI subjects.The frequencies of 4G/4G genotype in the AMI group were higher than those in the control group and higher in patient with STEMI than in patient with NSTEMI. Plasma levels of PAI-1 in subjects with 4G/4G genotype were significantly increased as compared to those in subjects with 4G/5G and 5G/5G genotype. Conclusions Plasma PAI-1 levels were associated with different myocardial infarction type, and PAI-1 promoter 4G/5G polymorphisms and CRP may be related to plasma PAI-1 levels     

Detailed comparison of intra-stent conditions 12 months after implantation of everolimus-eluting stents in patients with ST-segment elevation myocardial infarction or stable angina pectoris

Background

The differences in lesion morphology between ST-segment elevation myocardial infarction (STEMI) and stable angina (SAP) significantly influence chronic intra-stent conditions after first-generation drug-eluting stent implantation. The study aimed to compare the intra-stent conditions 12 months after implantation of a second-generation everolimus-eluting stent (EES) in patients with STEMI or SAP.

Methods and results

We examined the lesion morphology before EES implantation in 53 patients (23 STEMI, 30 SAP) using virtual histology intravascular ultrasound. We maintained dual anti-platelet therapy for 12 months and subsequently analyzed intra-stent conditions using optical coherence tomography and angioscopy. Pre-intervention plaque and necrotic core volume/length, remodeling index, and the incidence of thin-cap fibroatheroma and thrombus were significantly greater in STEMI than in SAP. After 12 months, the median neointimal thickness (117.6 μm vs. 126.0 μm), frequency of uncovered struts (1.2% ± 2.3% vs. 1.0% ± 2.3%), and percentage of stents fully covered with neointima (60.9% vs. 61.1%) were similar between the 2 groups. Meanwhile, the frequency of malapposed struts (0.4% ± 0.6% vs. 0.1% ± 0.4%, p = 0.04) and neointimal unevenness score (1.74 ± 0.21 vs. 1.64 ± 0.16, p = 0.04) were significantly higher in STEMI than in SAP. The neointimal color grade was more xanthochromatic in STEMI than in SAP. However, the differences were not associated with the incidence of clinical events and intra-stent thrombus (21.7% vs. 16.7%, p = 0.89).

Conclusions

Although a small degree of delayed healing still persists with second-generation EES, EES promotes a favorable arterial healing response in patients with STEMI, as well as those with SAP.     

Aborted myocardial infarction in intracoronary compared with standard intravenous abciximab administration in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Backgound

Abciximab reduces major adverse cardiac events (MACEs) in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Intracoronary (IC) abciximab bolus application might be more effective than a standard intravenous (IV) bolus. So far the occurrence of aborted MI, a new therapeutic target of effective treatment in STEMI, has not been evaluated in IC versus IV abciximab administration in STEMI patients undergoing primary PCI.

Methods

To investigate the extent of aborted MI, 154 patients undergoing primary PCI were randomized to either IC (n = 77) or IV (n = 77) bolus abciximab administration with subsequent 12-hour intravenous infusion. For assessment of infarct size and extent of microvascular obstruction, all patients underwent late enhancement magnetic resonance imaging (MRI). Aborted MI was defined by major (≥ 50%) ST-segment resolution and a lack of subsequent cardiac enzyme rise ≥ 2 the upper normal limit. We also assessed the occurrence of true aborted MI defined as the absence of myocardial necrosis in MRI.

Results

The incidence of aborted MI was significantly higher in the IC group (p = 0.04); true aborted MI was only observed in the IC abciximab group (p = 0.01). At multivariable logistic regression analysis, IC abciximab application was a significant independent predictor of true aborted MI (p = 0.03). Aborted MI patients had an excellent prognosis at 6-month follow-up with no MACE as compared to 24 events in patients with non-aborted MI.

Conclusions

IC bolus application of abciximab in STEMI patients undergoing primary PCI results in a higher incidence of aborted MI and subsequent improved clinical outcome.     

三项生化指标联合检测在急性冠状动脉综合征患者临床诊断中的意义

目的探讨心肌肌钙蛋白T(cTnT)和N末端B型钠尿肽前体(NT-proBNP)及高敏C反应蛋白(hs-CRP)3项生化指标联合检测在急性冠状动脉综合征(ACS)临床诊断中的应用价值。方法选择ACS患者134例,其中不稳定性心绞痛(UAP组)患者49例,ST段抬高心肌梗死(STEMI组)患者37例,非ST段抬高心肌梗死(NSTEMI组)患者48例。用电化学发光双抗体夹心法检测cTnT、NT-proBNP,免疫透射比浊法检测hs-CRP;通过绘制ROC曲线和建立logistic回归模型,分析各指标单独和联合检测在UAP、NSTEMI及STEMI诊疗中的作用。结果 UAP组(除外cTnT)、NSTEMI组及STEMI组患者血清cTnT、NT-proBNP、hs-CRP水平明显高于对照组,差异有统计学意义(P<0.05)。与cTnT、NT-proBNP、hs-CRP单独检测比较,3项指标联合检测ACS各组ROC曲线下面积最大,敏感性和特异性最好。结论联合检测cTnT、NT-proBNP、hs-CRP能明显改善ACS中UAP的诊断效果,对于NSTEMI和其他急性心肌梗死也能使敏感性和特异性达到最优化,但对区分NSTEMI和其他急性心肌梗死效果不明显。     

Prognostic significance of NT-proBNP, 3D LA volume and LV dyssynchrony in patients with acute STEMI undergoing primary percutaneous intervention

Objectives

The aim of the present study was to assess the short term prognostic significance of N-terminal pro BNP (NT-proBNP), 3D left atrial volume (LAV) and left ventricular (LV) dyssynchrony in patients of acute ST-elevation myocardial infarction (STEMI) who underwent primary Percutaneous intervention (PCI).

Background

NT-proBNP, LV dyssynchrony and LAV in patients with acute coronary syndrome have been associated with PCI outcomes and predict the short and long-term prognosis.

Methods

This study consisted of 142 patients with a first STEMI who underwent primary PCI. Baseline echocardiographic data was collected at admission and at 6 months follow up. Left ventricular dyssynchrony was measured by tissue Doppler imaging and LAV by real time 3D-echocardiography, plasma NT-proBNP levels were estimated between 72 and 96 h of admission.

Results

During study period 3 patients expired and 4 developed congestive heart failure (CHF). Baseline NT-proBNP and LV dyssynchrony correlated with LV size and LV ejection fraction (LVEF) at baseline and during follow up. Patients with higher NT-proBNP levels and higher LV dyssynchrony showed significant increase in LV size with decrease in LVEF during follow-up. Baseline Left atrial volume index (LAVI) showed significant correlation with LV size but no association with LVEF at baseline and during follow-up.

Conclusions

Higher levels of NT-proBNP and higher LV dyssynchrony can predict patients with increase in LV size, worsening of LV systolic and diastolic function during follow-up. Patients with higher NT-proBNP levels at baseline developed CHF during follow-up.     

Differences in Monocyte Subsets and Monocyte-Platelet Aggregates in Acute Myocardial Infarction—PreliminaryResults

Background

Monocyte-platelet interaction may favor the development of a proatherogenic monocyte phenotype. It is still uncertain which of the 3 monocyte subpopulations interact with platelets to form monocyte-platelet aggregates (MPAs) in acute myocardial infarctions. The aim of our study was to evaluate the monocyte subsets, the percentage of MPAs and the involvement of monocyte subsets in MPA formation among patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), and compared to patients with stable angina (SA).

Association of aortic stiffness with biomarkers of myocardial wall stress after myocardial infarction

Background

Aortic pulse wave velocity (PWV) was linked to LV-geometry and -function in patients with kidney disease and non-ischemic cardiomyopathy. The role of aortic compliance after acute STEMI is so far unknown. In the present study, we prospectively investigated the relationship of increased aortic stiffness with biomarkers of myocardial wall stress 4 months after STEMI.

Methods

48 STEMI patients who were reperfused by primary coronary angioplasty underwent cardiovascular magnetic resonance (CMR) at baseline and at 4-month follow-up. The CMR protocol comprised cine-CMR as well as gadolinium contrast-enhanced CMR. Aortic PWV was determined by velocity-encoded, phase-contrast CMR. Blood samples were routinely drawn at baseline and follow-up to determine N-terminal pro-B-type natriuretic peptide (NT-proBNP). In a subgroup of patients, mid-regional pro-adrenomedullin (MR-proADM) and mid-regional pro-A-type natriuretic peptide (MR-proANP) levels were determined.

Results

Patients with a PWV above median (> 7.0 m/s) had significantly higher NT-proBNP, MR-proADM and MR-proANP concentrations at 4-month follow-up than patients with a PWV below median (all p < 0.02). PWV showed moderate to good correlation with NT-proBNP, MR-proAMD and MR-proANP levels 4 months after STEMI (all p < 0.05). Multivariate analysis revealed PWV, beside myocardial infarct size, as an independent predictor of 4-month NT-proBNP levels after correction for age, creatinine and LV ejection fraction (model r: 0.781, p < 0.001).

Conclusion

Aortic stiffness is directly associated with biomarkers of myocardial wall stress 4 months after reperfused STEMI, suggesting a role for aortic stiffness in chronic LV-remodelling.