Effect of trimetazidine on myocardial salvage index in patients with acute ST segment elevation myocardial infarction undergoing primary PCI

IntroductionAcute STEMI is the most serious presentation of CAD. Restoration of the coronary flow facilitates cardiomyocyte salvage and decreases cardiac morbidity and mortality. However, reperfusion may result in paradoxical cardiomyocyte dysfunction, a phenomenon termed reperfusion injury. Trimetazidine is a metabolic anti-ischemic drug which is beneficial in reducing periprocedural myocardial reperfusion injury.The aim of the work is to study the effect of trimetazidine on myocardial salvage index in patients with acute STEMI who underwent primary PCI.MethodsForty patients presented with acute STEMI, underwent primary PCI with injection of an intravenous dose of Tc-99m labeled Sestamibi before primary PCI then first set of SPECT images were taken within 6 h from injection time to assess the initial size of the perfusion defect. Prior to discharge the patients received another dose of Tc-99m labeled Sestamibi and follow up SPECT images were taken to assess the final perfusion defect and to calculate myocardial salvage and myocardial salvage index.Twenty patients of them received trimetazidine before primary PCI (study group) and the other twenty patients did not receive trimetazidine (control group).Results(1) Patients with acute STEMI undergoing primary PCI who received trimetazidine before primary PCI had better myocardial salvage index, however it was statistically non significant. (2) Statistically significant better myocardial salvage index with post procedural TIMI 3 flow than with post procedural TIMI 2 flow among patients who received trimetazidine before primary PCI.ConclusionIn the presence of post procedural TIMI3 flow trimetazidine is beneficial in improving myocardial salvage index in patients presented with acute STEMI who underwent primary PCI.     

ST peak during primary percutaneous coronary intervention predicts final infarct size,left ventricular function,and clinical outcome

Background and Purpose

One third of patients treated with primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction develop a secondary increase in electrocardiographic ST segment (ST peak) during reperfusion. The purpose was to determine the clinical importance of ST peak during primary PCI.

Methods

A total of 363 patients with ST-elevation myocardial infarction were stratified to no ST peak or ST peak. Final infarct size and ejection fraction (EF) were assessed by cardiovascular magnetic resonance.

Results

Patients with ST peak had a larger infarct size (14% vs 10%; P = .003) and lower EF (53% vs 57%; P = .022). Rates of cardiac mortality (8% vs 3%; P = .047) and cardiac events (cardiac mortality and admission for heart failure; 19% vs 10%; P = .018) were higher among patients with ST peak, but not all-cause mortality (8% vs 5%; P = .46). In a multivariable Cox regression analysis, ST peak remained significantly associated with cardiac events (adjusted hazard ratio, 2.03 [1.08-3.82]).

Conclusion

ST peak during primary PCI is related to larger final infarct size, a reduced EF, and adverse cardiac clinical outcome.     

ST‐Segment Resolution Prior to Primary Percutaneous Coronary Intervention Is a Poor Indicator of Coronary Artery Patency in Patients with Acute Myocardial Infarction

Background: The prognostic value of ST‐segment resolution (STR) after initiation of reperfusion therapy has been established by various studies conducted in both the thrombolytic and mechanic reperfusion era. However, data regarding the value of STR immediately prior to primary percutaneous coronary intervention (PCI) to predict infarct‐related artery (IRA) patency remain limited. We investigated whether STR prior to primary PCI is a reliable, noninvasive indicator of IRA patency in patients with ST‐segment elevation myocardial infarction (STEMI). Methods: The study population consisted of STEMI patients who underwent primary PCI at our institution between 2000 and 2007. STR was analyzed in 12‐lead electrocardiograms recorded at first medical contact and immediately prior to primary PCI and defined as complete (≥70%), partial (70%? 30%), or absent (<30%). Results: In 1253 patients with a complete data set, STR was inversely related to the probability of impaired preprocedural flow (P_{for trend} < 0.001). Although the sensitivity of incomplete (<70%) STR to predict a Thrombolysis in Myocardial Infarction (TIMI) flow of <3 was 96%, the specificity was 23%, and the negative predictive value of incomplete STR to predict normal coronary flow was only 44%. Conclusions: This study establishes the correlation between STR prior to primary PCI and preprocedural TIMI flow in STEMI patients treated with primary PCI. However, the negative predictive value of incomplete STR for detection of TIMI‐3 flow is only 44% and therefore should not be a criterion to refrain from immediate coronary angiography in STEMI patients. Ann Noninvasive Electrocardiol 2010;15(2):107–115     

Impact of electrical neurostimulation on persistent ST elevation after successful reperfusion by primary percutaneous coronary intervention

Aims

To study the effect of electrical neurostimulation on the ST segment shift in patients with ST elevation myocardial infarction (STEMI) with residual ST elevation after primary percutaneous coronary intervention (PCI).

Methods

After primary PCI, 38 patients with STEMI were divided into 2 groups. Group 1 received 15 minutes of active neurostimulation after the baseline electrocardiogram (ECG); group 2 received 15 minutes of active neurostimulation after 15 minutes of nonactive neurostimulation.

Results

In group 1, ST elevation decreased with neurostimulation from 0.65 ± 0.56 to 0.55 ± 0.51 (P = .02) and to 0.50 ± 0.52 (P = .01) without electrical neurostimulation. In group 2, ST elevation changed without neurostimulation from 0.37 ± 0.32 to 0.33 ± 0.30 (P = NS) and to 0.28 ± 0.27 (P = .01) with electrical neurostimulation. In a posthoc analysis, 17 responders had higher ST elevation at the ECG before active electrical neurostimulation than 21 nonresponders (P = .001).

Conclusion

Electrical neurostimulation may result in significant additional reduction of ST elevation in STEMI after reperfusion treatment, in particular in patients with marked ST elevation on the first ECG after successful primary PCI.     

Acesso à Terapia de Reperfusão e Mortalidade em Mulheres com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST: Registro VICTIM

Background:Myocardial reperfusion is a fundamental part of the treatment for ST elevation myocardial infarction (STEMI) and is responsible for reducing morbidity and mortality in affected patients. However, reperfusion rates are usually lower and mortality rates higher in women compared to men.Objectives:To evaluate the prevalence of the use of reperfusion therapies among women and men with STEMI in hospitals where percutaneous coronary intervention (PCI) is available in the state of Sergipe.Methods:This is a cross-sectional study that used data from the VICTIM Register. Patients diagnosed with STEMI admitted to the four hospitals (one public and three private) where PCI is available in the state of Sergipe were evaluated, from December 2014 to June 2018. A multivariate analysis with adjusted model using mortality as a dependent variable was made. In all analyses, the level of significance adopted was 5% (p < 0.05).Results:A total of 878 volunteers with a confirmed diagnosis of STEMI, of which 33.4% were women, were included in the study. Only 53.3% of the patients underwent myocardial reperfusion (134 women versus 334 men). Fibrinolysis was performed only in 2.3% of all patients (1.7% of women versus 2.6% of men; p = 0.422). The rate of primary PCI was lower (44% versus 54.5%; p = 0.003) and hospital mortality was higher (16.1% versus 6.7%; p < 0.001) in women than in men.Conclusion:Women have significantly lower rates of primary PCI and higher hospital mortality. Reperfusion rates were low in both sexes and there was a clear underutilization of thrombolytic agents.     

Management of multivessel coronary disease after ST elevation myocardial infarction treated by primary angioplasty

BACKGROUND: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but available data failed to consistently show a benefit in long-term clinical outcomes. METHODS: We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were defined as a composite of death, periprocedural myocardial infarction after staged, elective PCI, stroke, stent thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death, stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome. RESULTS: Group 1 patients underwent staged PCI 5.9 +/- 3.5 days after primary angioplasty. The mean length of follow-up was 13 months (392 +/- 236 days). The incidence of in-hospital MACE was 20.3% in Group 1 and 10.8% in Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037). In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure, which occurred in 15.6% of patients. CONCLUSIONS: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural myocardial infarction during the elective procedure.     

Recent trends in reperfusion in ST elevation myocardial infarction in a South Indian tier-3 city

AimsIn India, larger proportions of patients with ACS present with STEMI. We sought to study the recent trends of reperfusion in patients of acute STEMI.Methods and Results1905 patients presenting with acute STEMI enrolled. 1636 (86%) received some form of reperfusion therapy. Streptokinase, 1235 (65%) patients, was the most common mode of reperfusion therapy used followed by primary PCI (205, 10.7%) and tenecteplase (196, 10%). 269 (14%) did not receive any form of reperfusion therapy, the most common reason being late presentation in 230 (85.7%). Patients presenting with STEMI increased from 297 to 446 comparing first and last half-year of study period. The PCI and tenecteplase numbers increased from 19 to 68 and 27 to 97 respectively.ConclusionThere was 20% increase in STEMI every year. Younger patients are least likely to receive primary PCI or tenecteplase. 1 in 8 patients of STEMI did not receive any form of reperfusion therapy.     

Preprocedural TIMI flow and infarct size in STEMI undergoing primary angioplasty

Despite optimal epicardial recanalization, primary angioplasty for STEMI is still associated with suboptimal reperfusion in a relatively large proportion of patients. The aim the current study was to evaluate the impact of preprocedural TIMI flow on myocardial scintigraphic infarct size among STEMI undergoing primary angioplasty. Our population is represented by 793 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Poor preprocedural TIMI flow (TIMI 0–1) was observed in 645 patients (81.3 %). Poor preprocedural TIMI flow was associated with more hypercholesterolemia (p = 0.012), and a trend in lower prevalence of diabetes (p = 0.081). Preprocedural TIMI flow significantly affected scintigraphic and enzymatic infarct size. Similar findings were observed in the analysis restricted to patients with postprocedural TIMI 3 flow. The impact of preprocedural TIMI flow on scintigraphic infarct size was confirmed when the analysis was performed according to the percentage of patients above the median (p < 0.001) and after adjustment for baseline confounding factors (Hypercholesterolemia and diabetes) [adjusted OR (95 % CI) for pre preprocedural TIMI 3 flow = 0.59 (0.46–0.75), p < 0.001]. This study shows that among patients with STEMI undergoing primary angioplasty, poor preprocedural TIMI flow is independently associated with larger infarct size.     

盐酸替罗非班对急性ST段抬高型心肌梗死患者急诊冠状动脉介入术心肌灌注的影响

目的:探讨盐酸替罗非班对急性ST段抬高型心肌梗死(STEMI)患者行急诊冠状动脉介入术(PCI)后心肌组织的再灌注影响。方法:符合STEMI入选标准的患者69例,随机分为治疗组(32例)和对照组(37例)。治疗组术前常规给予低分子肝素、阿司匹林、氯吡格雷、调脂药等治疗,术中加用盐酸替罗非班以输液泵持续泵入;对照组除未加盐酸替罗非班外,其他治疗同治疗组。2组术中都常规应用普通肝素。联合应用TMP(TIMI myocardial perfusion)和sumSTR(sum-ST-segment resolution)方法对心肌组织的灌注进行评价。结果:2种评价方法均显示治疗组急诊PCI后心肌组织的再灌注优于对照组(均P<0.05)。结论:盐酸替罗非班能明显改善STEMI患者急诊PCI后心肌组织的再灌注水平。     

Factors Associated With the Use of Bare Metal Stents in Patients With ST Elevation Myocardial Infarction

BackgroundDrug eluting stents (DES) are used in the majority of patients undergoing percutaneous coronary intervention (PCI). Factors associated with the use of bare metal stents (BMS) for patients undergoing primary PCI for ST elevation myocardial infarction (STEMI) have not been adequately explored. The objective of this study was to evaluate factors associated with BMS use in STEMI patients undergoing primary PCI.MethodsPatients undergoing primary PCI for STEMI between January 2008 and February 2015 were retrospectively identified. Patients who received both a DES and BMS were included in the DES group and patients receiving balloon angioplasty only were excluded. Baseline demographics, angiographic variables, procedure related variables and in-hospital events were collected. Multivariate analysis was performed to identify factors associated with BMS use.ResultsEight hundred and sixty-five patients underwent primary PCI for STEMI during the study period. Seventy-two patients (8.3%) received balloon angioplasty only and were excluded, yielding 793 patients for the study cohort. Three hundred fifty-two patients (44%) received BMS and 441 patients (56%) received DES. Patients receiving DES had a higher prevalence of diabetes mellitus, prior myocardial infarction, prior PCI, left anterior descending artery culprit location and Medicaid Insurance compared to those receiving BMS. Patients receiving BMS had a higher prevalence of cardiogenic shock and right coronary artery culprit location. Unadjusted in-hospital mortality was significantly higher for patients receiving BMS compared to patients receiving DES, 11.1% vs 3.2%, respectively, p < 0.0001. Multivariate predictors of BMS use were cardiogenic shock (OR 30.3; 95% CI 11.25 to 81.73) and diabetes mellitus (OR 2.99; 95% CI 1.04 to 8.64).ConclusionIn a contemporary series of patients undergoing primary PCI for STEMI, BMS were used in 44% of patients and independent factors associated with BMS use were cardiogenic shock and diabetes mellitus.     

Primary coronary angioplasty in patients with ST segment elevation acute myocardial infarction and diabetes

BACKGROUND: Subjects with diabetes constitute 13-25% of patients with ST segment elevation acute myocardial infarction (STEMI). In spite of the introduction of thrombolytic therapy, patients with STEMI and diabetes continue to have worse prognosis than those without diabetes. Primary percutaneous coronary intervention (PCI) has been shown in recent years to be the most effective therapy in patients with STEMI. AIM: To compare the outcome of STEMI patients with or without diabetes who underwent primary PCI. METHODS: The study group consisted of 500 consecutive patients with STEMI. The occurrence of major adverse cardiac events (MACE) which included death, reinfarction or repeated PCI of the target vessel, was analysed peri-operatively and during a six-month follow-up period.Results. Diabetes was diagnosed in 68 (13.6%) patients. The mean time duration from the onset of STEMI symptoms to treatment was similar in patients with or without diabetes (230+/-97 min vs 231+/-139 min, NS). Patients with diabetes were older (61.9+/-8.9 vs 57.9+/-10.8 years, p=0.004), had higher body mass index (29+/-4 vs 27+/-5, p=0.002), more frequent history of coronary artery disease (57.4% vs 37.9%, p=0.002), higher prevalence of arterial hypertension (71.6% vs 56.8%, p=0.02) and more frequently the left anterior descending artery as the infarct-related artery (58.8% vs 42.1%, p=0.01). Immediately after PCI, epicardial and myocardial reperfusion rates were lower in patients with rather than without diabetes (TIMI 3: 84.9% vs 91.3%, p=NS, cTFC: 32+/-26 vs 22+/-16, p<0.0001, and MPG3: 25% vs 41.9% p=0.008). Diabetes increased the risk of MACE during in-hospital period by 2.7 times. The rate of MACE during a six-month follow-up period was almost two times higher in patients with rather than without diabetes (death: 8.8% vs 5.1%, reinfarction: 1.5% vs 1.2%, repeated PCI: 11.8% vs 6.9%). CONCLUSIONS: Primary PCI-achieved epicardial and myocardial reperfusion rate is lower in STEMI patients with rather than without diabetes. The presence of diabetes almost doubles the risk of MACE during a six-month follow-up.     

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis

BackgroundPrimary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST.MethodsA sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed.ResultsMale patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%.ConclusionIn-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.     

Early phosphatemia changes in acute cardiac care patients

IntroductionThe significance of inorganic serum phosphate levels (Pi) in patients with acute coronary syndromes (ACS) in the reperfusion era is unknown, as well as its relation to biomarkers of myocardial necrosis. Our aim was to assess admission Pi and its dynamics in patients admitted to the intensive cardiac care unit (ICCU), with emphasis on patients with ST segment elevation myocardial infarction (STEMI).MethodsWe studied 192 patients admitted to the ICCU during a 4-month period. The first group included 92 patients with STEMI (STEMI group) treated by primary percutaneous coronary intervention (PCI). The second group consisted of 100 patients without ACS (non-ACS group). Normophosphatemia was defined as Pi 0.7–1.6 mmol/l. Phosphatemia was measured at admission and then 6 h and 12 h later as well as troponin I.ResultsAdmission phosphatemia was lower in the STEMI group as compared to the non-ACS group (Pi 0.95 mmol/l vs. 1.18 mmol/l, p<0.001). Admission hypophosphatemia (Pi<0.7 mmol/l) was more often present in the STEMI group than in the non-ACS group (21% vs. 4%, p=0.001). In all hypophosphatemic STEMI patients, serum Pi normalized itself within 6 h without substitution. Admission hyperphosphatemia (Pi>1.6 mmol/l) was more frequent in non-ACS group (6.5% STEMI pts. vs. 13% non-ACS pts.). In the STEMI group, admission phosphatemia did not correlate with peak troponin I.ConclusionWe conclude that patients with STEMI treated by primary PCI have lower Pi and more frequent transient hypophosphatemia at admission than acute cardiac care patients without acute coronary syndrome.     

A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals

BACKGROUND:

Historically, access to primary percutaneous coronary intervention (PCI) for the treatment of patients with ST segment elevation myocardial infarction (STEMI) has been limited in Canada. Recent studies have identified innovative strategies to improve timely access and reduce reperfusion time. Accordingly, the contemporary use of primary PCI treatment in Canada was ascertained.

METHODS:

A cross-sectional survey of all 38 Canadian hospitals that were capable of performing PCI procedures was conducted from June 2007 to November 2007. The survey focused on the practice of primary PCI for patients with STEMI and whether the hospitals had implemented internal strategies to reduce ‘door-to-balloon’ times. Analyses were performed at the level of geographical regions.

RESULTS:

Overall, 71% of PCI hospitals (27 of 38) provided around-the-clock primary PCI for patients with STEMI, but the proportion of PCI hospitals offering this service varied widely, from 33% to 100% across regions. All Canadian PCI hospitals provided around-the-clock rescue PCI treatment to STEMI patients who had failed fibrinolytic therapy. In terms of strategies that are associated with reduced reperfusion time, it was observed that only 42% of PCI hospitals (16 of 38) provided feedback on door-to-balloon time to the emergency department and to the cardiac catheterization laboratories within one week of the primary PCI procedure. Overall, 24% of the hospitals had not adopted any of the four identified strategies to improve door-to-balloon time.

CONCLUSION:

Although the majority of Canadian hospitals with PCI capability provide around-the-clock primary PCI for patients with STEMI, significant variations in this practice exist across the country. Canadian PCI hospitals have not consistently adopted strategies that are associated with improved door-to-balloon time.     

Impacto na mortalidade da admissão direta versus transferência inter‐hospitalar nos doentes com enfarte agudo do miocárdio com elevação do segmento ST submetidos a intervenção coronária percutânea primária

IntroductionIn a primary percutaneous coronary intervention (PCI) program, interhospital transfer of patients with ST‐elevation myocardial infarction (STEMI) can increase ischemic time, compared to patients who are admitted directly to a catheterization laboratory.ObjectivesTo assess the impact of interhospital transfer in patients with STEMI undergoing primary PCI, in terms of time to reperfusion and one‐year mortality.MethodsThis was an observational, retrospective, longitudinal study of patients with STEMI admitted to Hospital de Braga between June 2011 and May 2016, who were treated successfully within 12 hours of symptom onset. A total of 1222 patients were included and divided into two groups according to admission to Hospital de Braga: direct or interhospital transfer.ResultsIn this study, 37.0% (n=452) of the population were admitted directly to Hospital de Braga and 63.0% (n=770) were transferred from other hospitals. Although timings (in min) until reperfusion were longer in interhospital transfer patients (symptom onset‐first medical contact (median 76.5, IQR 40.3‐150 vs. 91.0, IQR 50‐180, p=0.002), first medical contact‐reperfusion (median 87.5, IQR 69.0‐114 vs. 145, IQR 115‐199, p<0.001) and symptom onset‐reperfusion (median 177, IQR 125‐265 vs. 265, IQR 188‐400, p<0.001)), one‐year mortality did not differ significantly between the groups (53 [11.7%] vs. 71 [9.2%], p=0.193). In multivariate analysis, age, symptom onset‐reperfusion time and especially Killip class IV at admission (HR 11.2, 95% CI 6.35‐19.8, p<0.001) were the main independent predictors of one‐year mortality.ConclusionInterhospital transfer of patients with STEMI increased the time before PCI. No differences were detected between groups in one‐year mortality. This may be related to the fact that the direct admission group had twice as many patients in Killip class IV as the interhospital transfer group.     

The Global Effect of the COVID-19 Pandemic on STEMI Care: A Systematic Review and Meta-analysis

BackgroundThe COVID-19 pandemic has affected patients with ST-segment elevation myocardial infarction (STEMI) requiring primary percutaneous coronary intervention (PCI) worldwide. In this review we examine the global effect of the COVID-19 pandemic on incidence of STEMI admissions, and relationship between the pandemic and door to balloon time (D2B), all-cause mortality, and other secondary STEMI outcomes.MethodsWe performed a systematic review and meta-analysis to primarily compare D2B time and in-hospital mortality of STEMI patients who underwent primary PCI during and before the pandemic. Subgroup analyses were performed to investigate the influence of geographical region and income status of a country on STEMI care. An online database search included studies that compared the aforementioned outcomes of STEMI patients during and before the pandemic.ResultsIn total, 32 articles were analyzed. Overall, 19,140 and 68,662 STEMI patients underwent primary PCI during and before the pandemic, respectively. Significant delay in D2B was observed during the pandemic (weighted mean difference, 8.10 minutes; 95% confidence interval [CI], 3.90-12.30 minutes; P = 0.0002; I² = 90%). In-hospital mortality was higher during the pandemic (odds ratio [OR], 1.27; 95% CI, 1.09-1.49; P = 0.002; I² = 36%), however this varied with factors such as geographical location and income status of a country. Subgroup analysis showed that low–middle-income countries observed a higher rate of mortality during the pandemic (OR, 1.52; 95% CI, 1.13-2.05; P = 0.006), with a similar but insignificant trend seen among the high income countries (OR, 1.17; 95% CI, 0.95-1.44; P = 0.13).ConclusionsThe COVID-19 pandemic is associated with worse STEMI performance metrics and clinical outcome, particularly in the Eastern low–middle-income status countries. Better strategies are needed to address these global trends in STEMI care during the pandemic.     

Intracoronary ST segment evolution during primary coronary stenting predicts infarct zone recovery

In patients with acute myocardial infarction (AMI), early ST segment elevation resolution on ECG predicts myocardial reperfusion and LV recovery. Intracoronary ECG is more sensitive than surface ECG to detect regional ischemia. In patients undergoing primary percutaneous coronary intervention (PCI), we investigated if failed myocardial reperfusion, despite successful infarct vessel recanalization, could be rapidly and easily identified by intracoronary ST segment monitoring from guidewire recording. We recorded intracoronary and standard ECG during primary coronary stenting (PCI) in 50 patients with AMI (59 ± 11 years; anterior AMI in 66%). All patients had a successful PCI and underwent 2D echocardiography soon after PCI and 6 months later. Following PCI, intracoronary ST resolution ≥ 50% from baseline was documented in 39 patients (78%; group A; from 11 ± 8 to 1 ± 2 mm) but not in 11 (22%; group B; from 11 ± 8 to 8 ± 5 mm). Group A had slightly shorter ischemic time (202 ± 94 vs. 238 ± 112 min in B; P = 0.2) and smaller peak CK values (2,752 ± 2,038 vs. 4,802 ± 3,671 U/L in B; P = 0.02). After PCI, ST resolution was found on standard ECG in 34 (87%) group A and in 3 (27%) group B patients. At 6‐month follow‐up, left ventricular ejection fraction was greater in group A (47% ± 8% vs. 39% ± 8% in B; P < 0.001) with improved wall motion score index (from 2.2 ± 0.3 to 1.7 ± 0.3 in A; from 2.3 ± 0.4 to 2.1 ± 0.4 in B; P < 0.001). There were no significant differences between intracoronary and standard ECG for sensitivity (92% vs. 86%) and specificity (62% vs. 57%) to predict improved infarct zone recovery after 6 months. ST elevation resolution on intracoronary recording during PCI predicts infarct zone recovery. Monitoring ST segment evolution by intracoronary ECG allows prompt and inexpensive identification in the catheterization laboratory of those patients without myocardial reperfusion, who may require adjunctive therapeutic interventions after successful infarct vessel recanalization. Catheter Cardiovasc Interv 2005;64:53–60. © 2004 Wiley‐Liss, Inc.     

Prognostic value of Angiographic Perfusion Score (APS) following percutaneous interventions in acute coronary syndromes

IntroductionIdentifying reperfusion and predicting post procedure risk is important following Percutaneous Coronary Interventions (PCI). An Angiographic Perfusion Score (APS) combining TIMI flow (TFG) and myocardial perfusion (TMPG) grades before and after PCI can accurately measure both epicardial and myocardial perfusion and predict Major Adverse Cardiac Events (MACE).Patients and methodsAPS was calculated in 226 (88 ST elevation Myocardial Infarction (STEMI) and 138 Non STEMI) patients. Maximum score being 12, reperfusion was defined as failed: 0–3, partial: 4–9, and full APS: 10–12. Thirty day MACE were observed.ResultsAPS identified reperfusion significantly more than TMPG alone (STEMI: 50.6% vs 11.8% (p < 0.001); Non STEMI, early reperfusion: 69.4% vs 52.8% (p < 0.01) and Non STEMI late reperfusion: 38.2% vs 7.8%; (p ≤ 0.001) respectively. A significantly lower incidence of MACE was observed in the full as compared to the failed APS group (1.8% vs 22.5%) (p < 0.001). No differences were noted between TMPG 0–2 (9.8%, 9.4%, 7.3%, respectively) (p = NS).ConclusionCompared to MPG alone APS detects more low risk reperfused patients, post PCI.     

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 thrombus aspiration use and direct stenting on final myocardial blush score in patients presenting with ST-elevation myocardial infarction

BackgroundMany studies have reported that low final thrombolysis in myocardial infarction (TIMI) flow and/or myocardial blush grade (MBG) are independent predictors of mortality in patients with ST-elevation myocardial infarction (STEMI). In addition, distal coronary embolization is a major pitfall of conventional percutaneous coronary intervention (PCI) in such a context.AimThis study aimed to assess the impact of thrombus aspiration (TA) use before primary PCI on final myocardial reperfusion in patients presenting with STEMI.MethodsFrom January to December 2006, 100 patients presenting with STEMI in our catheterization laboratory were considered for the present study. During this time period, 50 patients underwent TA before primary PCI for treatment of STEMI and were then matched 1:1 to 50 controls who underwent conventional primary PCI for treatment of STEMI without TA. Patients of the control group were chosen after matching on age±3 years, sex, history of diabetes, and distribution of the infarct related coronary artery during the same period.ResultsBaseline clinical characteristics, initial TIMI flow and initial MBG of both groups were similar. There was a trend for a better final TIMI flow in the group with TA and the final MBG was significantly improved in the group with TA compared to the group without TA: final MBG of two or three in 70% versus 30% of the cases (P=.001). In addition, direct stenting was significantly more often used in the TA group (92% versus 64%, P=.001). There were four patients with evident distal embolizations in the group without TA and none in the group with TA.ConclusionTA use before primary PCI for STEMI treatment resulted in improved final myocardial reperfusion. Of importance, TA use may have led to a better choice of the stent size and more frequent direct stenting. This benefit may directly improve patient outcomes.