A randomized study of prourokinase during primary percutaneous coronary intervention in acute ST‐segment elevation myocardial infarction

Objectives

To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions (PCI) in patients with acute ST‐segment elevation myocardial infarction (STEMI).

Methods

Acute STEMI patients underwent primary PCI were randomly divided into two groups: intracoronary prourokinase (IP) group (n = 118) and control group (n = 112). During primary PCI, prourokinase or saline were injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and MACE occurred in the 6‐months follow up were recorded.

Results

No significant differences were observed between two groups with respect to baseline demographic, clinical, and angiographic characteristics (P > 0.05). In IP group, more patients had complete ST segment resolution (>70%) compared with control group (P < 0.05). Patients in IP group showed lower levels of serum CK, CK‐MB and TnI, and a much higher myocardial blood flow (MBF) than those in control group (P < 0.05). No significant differences of TIMI major or minor bleeding complications were observed between the two groups (P > 0.05). At 6‐months follow‐up, there was a trend that patients in the IP group had a less chance to have MACE, though it was not statistically different (8.5% vs 12.5%, P > 0.05).

Conclusions

Intracoronary administration of prourokinase via balloon catheter during primary PCI effectively improved myocardial perfusion in STEMI patients.     

Sustained sex‐based treatment differences in acute coronary syndrome care: Insights from the American Heart Association Get With The Guidelines Coronary Artery Disease Registry

Background

Sex‐based differences in acute coronary syndrome (ACS) mortality may attenuate with age due to better symptom recognition and prompt care.

Hypothesis

Age is a modifier of temporal trends in sex‐based differences in ACS care.

Methods

Among 104 817 eligible patients with ACS enrolled in the AHA Get With the Guidelines–Coronary Artery Disease registry between 2003 and 2008, care and in‐hospital mortality were evaluated stratified by sex and age. Temporal trends within sex and age groups were assessed for 2 care processes: percentage of STEMI patients presenting to PCI‐capable hospitals with a DTB time ≤ 90 minutes (DTB90) and proportion of eligible ACS patients receiving aspirin within 24 hours.

Results

After adjustment for clinical risk factors and sociodemographic and hospital characteristics, 2276 (51.7%) women and 6276 (56.9%) men with STEMI were treated with DTB90 (adjusted OR: 0.85, 95% CI: 0.80–0.91, P < 0.0001 for women vs men). Time trend analysis showed an absolute increase ranging from 24% to 35% in DTB90 rates among both men and women (P for trend <0.0001 for each group), with consistent differences over time across the 4 age/sex groups (3‐way P‐interaction = 0.93). Despite high rate of baseline aspirin use (87%–91%), there was a 9% to 11% absolute increase in aspirin use over time, also with consistent differences across the 4 age/sex groups (all 3‐way P‐interaction ≥0.15).

Conclusions

Substantial gains of generally similar magnitude existed in ACS performance measures over 6 years of study across sex and age groups; areas for improvement remain, particularly among younger women.     

The ratio of contrast volume to glomerular filtration rate predicts outcomes after percutaneous coronary intervention for ST‐segment elevation acute myocardial infarction

Objective: To assess the value of the ratio between contrast medium volume and glomerular filtration rate (CMGFRr) for prediction of development of contrast‐induced nephropathy (CIN) and mortality in patients with ST‐segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Background: Renal function is a strong predictor of outcome in patients with STEMI. CIN may complicate the course of primary PCI in these patients. Methods: The study population included all 871 consecutive patients with STEMI without cardiogenic shock who underwent primary PCI at our center from January 1, 2001, to October 30, 2006. CIN was defined as an absolute increase in serum creatinine > 0.5 mg/dL or a relative increase >25% within 48 hr after PCI. Results: In‐hospital CIN developed in 72 (8.3%) patients. On linear regression analysis, the following variables were independently associated with CIN: male sex (odds ratio [OR] = 0.42, 95% confidence interval [CI], 0.18–0.97, P = 0.04), GFR < 60 (OR = 3.6, 95% CI, 2.79–4.78, P < 0.0001), multivessel coronary artery disease (OR = 1.67, 95% CI, 1.08–2.58, P = 0.02), CMGFRr (OR = 1.53, 95% CI, 1.01–2.31, P = 0.04, for upper tertile vs. lower two tertiles), and Killip class > 1 (OR = 1.35, 95% CI, 1.03–1.76, P = 0.03). CMGFRr > 3.7 was a strong independent predictor of CIN (OR = 3.87, 95% CI, 1.72–8.68, P = 0.001). Twenty‐six (2.9%) patients died at 1 month after PCI. The following variables were independently predictive of 1‐month mortality: CMGFRr > 3.7 (OR = 3.3, 95% CI, 1.22–9.04, P = 0.018) and multivessel coronary artery disease (OR = 2.3, 95% CI, 1.28–4.07, P = 0.005). Conclusion: The contrast medium‐to‐GFR ratio is a strong predictor of CIN and of 1‐month mortality in patients undergoing primary PCI for STEMI. © 2010 Wiley‐Liss, Inc.     

Thrombus aspiration in primary percutaneous coronary intervention in high‐risk patients with ST‐elevation myocardial infarction: A real‐world registry

Objectives : To evaluate the effect of thrombus aspiration in a real‐world all‐comer patient population with STEMI undergoing primary PCI. Background : Catheter thrombus aspiration in primary PCI was beneficial in randomized clinical trials. Methods : We enrolled 313 STEMI patients presenting with TIMI Flow Grade 0 or 1 in the infarct related artery at baseline angiogram undergoing primary PCI. Patients were divided in two groups based on whether thrombus aspiration was attempted. This decision was left at operator's discretion. Procedural and long‐term clinical outcomes were compared between the two groups. Results : Baseline characteristics were similar between groups: 194 (62%) received thrombus aspiration and 119 underwent conventional PCI. Thrombus aspiration was associated with significantly lower post‐PCI TIMI Frame Count values (19 ± 15 vs. 25 ± 17; P = 0.002) and higher TIMI Flow Grade 3 (92% vs. 73%; P < 0.001). Postprocedural myocardial perfusion assessed by myocardial blush grade (MBG) was significantly increased in the thrombus aspiration group (MBG 3: 44% vs. 21%; P < 0.001). No significant difference was found between the two groups in clinical outcome at 30 days. At one year, patients treated with thrombus aspiration showed significantly higher overall survival (HR 0.41, 95% CI 0.20–0.81; log‐rank P = 0.010) and MACE‐free survival (HR 0.49, 95% CI 0.28–0.85; log‐rank P = 0.011). Conclusions : In real‐world all‐comer STEMI patients with occluded infarct‐related artery, thrombus aspiration prior to PCI improves coronary flow, myocardial perfusion, and long‐term clinical outcome as compared with PCI in the absence of thrombus aspiration. © 2010 Wiley‐Liss, Inc.     

Interatrial block as a predictor of atrial fibrillation in patients with ST‐segment elevation myocardial infarction

Introduction

Interatrial block (IAB) is strongly associated with recurrence of atrial fibrillation (AF) in different clinical scenarios. Atrial fibrosis is considered the responsible mechanism underlying the pathogenesis of IAB. The aim of this study was to investigate whether IAB predicted AF at 12 months follow‐up in a population of patients with ST segment elevation myocardial infarction (STEMI).

Hypothesis

We aimed to investigate whether IAB predicted AF at 12 months follow up in a population of patients with STEMI.

Methods

Prospective, single center, observational study of patients presenting with ST‐segment elevation myocardial infarction (STEMI) and referred to primary percutaneous coronary intervention (P‐PCI). Surface electrocardiograms (ECG) were recorded on admission and at 6th hour post P‐PCI. Patients were screened for the occurrence of AF at a 12‐months visit.

Results

A total of 198 patients were included between September 2015 and September 2016. IAB (partial and advanced) was detected in 102 (51.5%) patients on admission. Remodeling of the P‐wave and subsequent normalization reduced the prevalence of IAB to 47 (23.7%) patients at 6th hour. AF was detected in 17.7% of study patients at 12 months. Partial IAB (p‐IAB) on admission (OR 5.10; 95% CI, 1.46‐17.8; P = 0.011) and on 6th hour (OR 4.15; 95% CI, 1.29‐13.4; P = 0.017), presence of a lesion in more than one coronary artery (OR 3.29; 95% CI, 1.32‐8.16; P = 0.010) found to be independent predictors of AF at 12 months.

Conclusion

IAB is common in patients with STEMI and along with the presence of diffuse coronary artery disease is associated with new onset of AF.     

Culprit plaque characteristics in women vs men with a first ST‐segment elevation myocardial infarction: In vivo optical coherence tomography insights

Background

It is unclear whether more severe coronary atherosclerosis is a prerequisite to an initial acute coronary event in women vs men.

Hypothesis

Women may have more severe coronary atherosclerosis than men in patients with acute coronary event.

Methods

We used intravascular optical coherence tomography (OCT) to evaluate gender differences in culprit‐plaque morphology in patients with a first ST‐segment elevation myocardial infarction (STEMI).We retrospectively enrolled 211 consecutive patients who experienced a first STEMI and underwent an OCT examination of their infarct‐related artery before primary percutaneous coronary intervention.

Results

Of the 211 patients enrolled, 162 (76.7%) were men and 49 (23.2%) were women. The women were significantly older than the men (mean age, 60.2 ± 8.2 vs 55.7 ± 11.2 years; P = 0.01) and less likely to be current smokers (P = 0.02). Moreover, the delay from symptom onset to reperfusion was longer in women than in men (7.6 ± 6.1 vs 5.5 ± 4.4 hours; P = 0.01). The OCT data indicated that there were no gender differences in culprit‐plaque morphology, including lipid length, lipid arc, minimum fibrous cap thickness, or minimum lumen area. Additionally, no gender differences were found in the prevalence of plaque rupture, thin‐cap fibroatheroma, residual thrombus, microvessels, macrophages, cholesterol crystals, or calcification.

Conclusions

Among patients presenting with a first STEMI, there were no differences in culprit plaque features between women and men.

     

Prognostic value of the age,creatinine, and ejection fraction score for non‐infarct‐related chronic total occlusion revascularization after primary percutaneous intervention in acute ST‐elevation myocardial infarction patients: A retrospective study

Objective

It is not known if ACEF scores could evaluate the prognosis of recanalization of non‐infarct‐related coronary arteries (non‐IRA) with chronic total occlusions (CTO) in patients who successfully underwent primary PCI. The objective of the current study was to assess the prognostic value of ACEF scores in acute ST‐segment elevation myocardial infarction (STEMI) patients with non‐IRA CTO after successful primary PCI.

Methods

There were 2952 STEMI patients who underwent successful primary PCI from January 2006 to December 2014 in our hospital, among them 377 patients had a non‐IRA CTO lesion. The patients were divided into successful CTO‐PCI group (n = 221) and failed/non‐attempted CTO‐PCI group (n = 156). Patients were stratified based on the ACEF tertiles. Primary end points measured in the current study were major adverse cardiac events (MACE) defined as the composite of all‐cause death, nonfatal myocardial infarction, ischemia‐driven coronary revascularization and hospitalization for heart failure at 1 year.

Results

The incidence of MACE, all‐cause death and cardiac death were higher in the failed/non‐attempted CTO‐PCI group (P < 0.001). In the successful CTO‐PCI group, the cumulative 1‐year incidences of MACE and all‐cause death were decreased compared to those in the failed/non‐attempted CTO‐PCI group (log‐rank P < 0.001). The risk for MACE was reduced in the successful CTO‐PCI group compared to the failed/non‐attempted CTO‐PCI group in patients with low and intermediate ACEF scores (log‐rank P = 0.02).

Conclusions

Successfully staged CTO‐PCI could gain advantageous clinical outcomes in those patients with low or intermediate ACEF scores.     

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.

     

Clinical impact of complete atrioventricular block in patients with ST‐segment elevation myocardial infarction

Complete atrioventricular block (CAVB) is a common complication of ST‐segment elevation myocardial infarction (STEMI). Although STEMI patients complicated with CAVB had a higher mortality in the thrombolytic era, little is known about the impact of CAVB on STEMI patients who underwent primary percutaneous coronary intervention (PCI). The study aimed at evaluating the clinical impact of CAVB on STEMI patients in the primary PCI era. We consecutively enrolled 1295 STEMI patients undergoing primary PCI within 24 hours from onset. Patients were divided into two groups according to the infarct location: anterior STEMI (n = 640) and nonanterior STEMI (n = 655). The outcomes were all‐cause death and major adverse cardiocerebrovascular events (MACCE) with a median follow‐up period of 3.8 (1.7–6.6) years. Eighty‐one patients (6.3%) developed CAVB. The incidence of CAVB was lower in anterior STEMI patients than in nonanterior STEMI (1.7% vs 10.7%, p < .05). Anterior STEMI patients with CAVB had a higher incidence of all‐cause deaths (82% vs 20%, p < .05) and MACCE (82% vs 25%, p < .05) than those without CAVB. Although higher incidence of all‐cause deaths was found more in nonanterior STEMI patients with CAVB compared with those without CAVB (30% vs 18%, p < .05), there was no significant difference in the incidence of MACCE (24% vs 19%). Multivariate analysis showed that CAVB was an independent predictor for all‐cause mortality and MACCE in anterior STEMI patients, but not in nonanterior STEMI. CAVB is rare in anterior STEMI patients, but remains a poor prognostic complication even in the primary PCI era.     

Selective drug‐eluting stent implantation for high‐risk patients with acute ST‐elevation myocardial infarction: Rationale and safety

Background : A selective policy of drug‐eluting stent (DES) implantation in ST‐elevation myocardial infarction (STEMI) patients at high risk of restenosis may maximize the benefit from restenosis reduction and minimize risk from late stent thrombosis (LaST). Objectives : We sought to prospectively determine the safety of selective DES implantation for long lesions (>20 mm), small vessels (<2.5 mm) and diabetic patients in patients with STEMI using a prospective single‐center registry. Methods : A total of 252 patients who underwent primary PCI between January 2005 and December 2006 were included: 126 consecutive patients receiving DES were compared with 126 age‐, sex‐, and vessel‐matched controls with STEMI who received bare‐metal stents. Composite major adverse cardiovascular events (MACE) (death, AMI, and target vessel revascularization) were used as the primary outcome measure. Results : Baseline clinical and angiographic characteristics and outcomes were similar between groups except for the prespecified diabetes, lesion length, and maximum stent diameter. Long‐term outcomes at a median follow up of 34 ± 6 months showed significant reductions in reinfarction (2% vs. 11%, P = 0.03), target vessel revascularization (TVR) (10% vs. 24%, P = 0.02), and composite MACE (18% vs. 31%, P = 0.03) with DES, with no excess of death (9% vs. 7%, P = NS) or LaST (2% vs. 1%, P = NS). In a Cox multivariate model, clopidogrel cessation at long‐term follow‐up was the most powerful predictor of hierarchical MACE (HR: 5.165; 95%CI: 2.019–13.150, P = 0.001). Conclusions : Selective DES implantation in patients with high‐risk STEMI appears safe, and exposes fewer patients to the risk of LaST. A randomized comparison of selective versus routine DES use in patients with STEMI should be considered. © 2010 Wiley‐Liss, Inc.     

Outcomes of primary percutaneous coronary intervention in acute myocardial infarction due to unprotected left main thrombosis: The Asia‐Pacific Left Main ST‐Elevation Registry (ASTER)

Introduction

Prior studies of ULM STEMI have been confined to small cohorts. Recent registry data with larger patient cohorts have shown contrasting results. We aim to study the outcomes of patients with unprotected left main (ULM) ST‐elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

Methods

The Asia‐pacific left main ST‐Elevation Registry (ASTER) is a multicenter retrospective registry involving 4 sites in Singapore, South Korea, and the United States. The registry included patients presenting with STEMI due to an ULM coronary artery culprit lesion who underwent emergency PCI. The primary outcome was in‐hospital mortality. Secondary outcomes included major adverse cardiovascular events.

Results

A total of 67 patients (mean age 64.2 ± 12.8 years, 53 [79.1%] males) were included. The distal left main bifurcation was most commonly involved (85%, n = 57). Fifty one (76%) patients had TIMI 3 flow post‐PCI. The in‐hospital mortality rate was 47.8% (n = 32); 61% (n = 41) had cardiac failure, 4% (n = 3) had emergency coronary artery bypass grafting, 1% (n = 1) had a re‐infarction, 3% (n = 2) had stroke and 55% (n = 37) had malignant ventricular arrhythmias. On multivariate analysis, predictors of in‐hospital mortality included older age (odds ratio (OR) 1.085 (95% confidence interval (CI) 1.002‐1.175), P = 0.044), diabetes mellitus (OR 10.882 (95%CI 11.074‐110.287), P = 0.043) and absence of post‐PCI TIMI 3 flow (OR 71.429 (95%CI 2.985‐1000), P = 0.008).

Conclusions

STEMI from culprit unprotected left main coronary artery stenosis is associated with significant mortality and morbidity. Emergency PCI provides an important treatment option in this high‐risk group, but in‐hospital mortality remains high.     

Effects of endovascular cooling on infarct size in ST‐segment elevation myocardial infarction: A patient‐level pooled analysis from randomized trials

Objectives

This study sought to examine the relationship between temperature at reperfusion and infarct size.

Background

Hypothermia consistently reduces infarct size when administered prior to reperfusion in animal studies, however, clinical results have been inconsistent.

Methods

We performed a patient‐level pooled analysis from six randomized control trials of endovascular cooling during primary percutaneous coronary intervention (PCI) for ST‐segment elevation myocardial infarction (STEMI) in 629 patients in which infarct size was assessed within 1 month after randomization by either single‐photon emission computed tomography (SPECT) or cardiac magnetic resonance imaging (cMR).

Results

In anterior infarct patients, after controlling for variability between studies, mean infarct size in controls was 21.3 (95%CI 17.4‐25.3) and in patients with hypothermia <35°C it was 14.8 (95%CI 10.1‐19.6), which was a statistically significant absolute reduction of 6.5%, or a 30% relative reduction in infarct size (P = 0.03). There was no significant difference in infarct size in anterior ≥35°C, or inferior infarct patients. There was no difference in the incidence of death, ventricular arrhythmias, or re‐infarction due to stent thrombosis between hypothermia and control patients.

Conclusions

The present study, drawn from a patient‐level pooled analysis of six randomized trials of endovascular cooling during primary PCI in STEMI, showed a significant reduction in infarct size in patients with anterior STEMI who were cooled to <35°C at the time of reperfusion. The results support the need for trials in patients with anterior STEMI using more powerful cooling devices to optimize the delivery of hypothermia prior to reperfusion.     

Arterial access and door‐to‐balloon times for primary percutaneous coronary intervention in patients presenting with acute ST‐elevation myocardial infarction

Objectives: This study compares the transradial versus the transfemoral approach for time to intervention for patients presenting with ST elevation myocardial infarction (STEMI). Background: Survival following STEMI is associated with reperfusion times (door‐to‐balloon; D2B). For patients undergoing primary PCI for acute STEMI, potential effects of transradial approach (r‐PCI) as compared with the femoral artery approach (f‐PCI) on D2B times have not been extensively studied. Methods: Consecutive patients presenting with STEMI at a tertiary care medical center were enrolled in a comprehensive—Heart Alert program (HA) and included in this analysis. Time parameters measured included: door‐to‐ECG, ECG‐to‐HA activation, HA activation‐to‐cath lab team arrival, patient arrival in cath lab to arterial access, and arterial access‐to‐balloon inflation. Results: Of 240 total patients, 205 underwent successful PCI (n = 124 r‐PCI; n = 116 f‐PCI). No significant difference was observed in the pre‐cath lab times. Mean case start times for r‐PCI took significantly longer (12.5 ± 5.4 min vs. 10.5 ± 5.7 min, P = 0.005) due to patient preparation. Once arterial access was obtained, balloon inflation occurred faster in the r‐PCI group (18.3 vs. 24.1 min; P < 0.001). Total time from patient arrival to the cardiac cath lab to PCI was reduced in the r‐PCI as compared to the f‐PCI group (28.4 vs. 32.7 min, P = 0.01). There was a small but statistical difference in D2B time (r‐PCI 76.4 min vs. f‐PCI 86.5 min P = 0.008). Conclusions: Patients presenting with STEMI can undergo successful PCI via radial artery approach without compromise in D2B times as compared to femoral artery approach. © 2009 Wiley‐Liss, Inc.     

Factors Associated With Ineligibility for PCI Differ Between Inpatient and Outpatient ST‐Elevation Myocardial Infarction

Objectives

Without early revascularization, both inpatient and outpatient STEMIs have poor outcomes. Reasons for denying PCI for STEMI, however, remain uncertain. This single‐center retrospective cohort study compares factors and outcomes associated with ineligibility for PCI between inpatients and outpatients following ST‐elevation myocardial infarction (STEMI).

Methods

A total of 1,759 STEMI patients between June 2009 and January 2015 were assessed. Individual medical records were reviewed to obtain reasons for PCI ineligibility for STEMI patients who did not receive reperfusion therapy.

Results

Compared to outpatients with STEMI (n = 1,688), inpatients (n = 71) were less likely to receive coronary angiography (60.6% vs 95.9%; P < 0.001) or PCI (50.7% vs 80.9%; P < 0.001), with longer ECG/door to first device activation times (97 [78, 131] vs 63 [49, 78] minutes; P < 0.001). When coronary angiography was performed, however, similar rates of PCI and procedural success were seen in both groups. Principal contraindication for PCI was risk of bleeding within the inpatient population and complex coronary artery disease within the outpatient population. Total in‐hospital mortality was higher in inpatient STEMIs compared to outpatients (42.2% vs 10.0%; P < 0.001), but lower for patients eligible for PCI in both groups.

Conclusions

Reasons for PCI ineligibility differ between inpatient and outpatient STEMIs. Inpatients have increased risks of bleeding, lower coronary angiography and PCI use, and higher in‐hospital mortality. Especially for inpatients, specific PCI STEMI protocols that anticipate and overcome types of ineligibility and delay for cardiac catheterization may improve outcomes.

     

Electrocardiographic diagnosis of atrial infarction in patients with acute inferior ST‐segment elevation myocardial infarction

Background

Patients with atrial myocardial infarction (ATMI) have frequent cardiac and noncardiac complications. However, ATMI is uncommonly diagnosed because of its nonspecific ECG changes. Our objective was to analyze the ECG characteristics of ATMI in patients with inferior STEMI.

Hypothesis

Electrocardiographic P wave parameters can help in diagnosis of ATMI.

Methods

We evaluated 932 patients who underwent coronary angiography and recruited 39 patients with ATMI and 33 patients without ATMI with inferior STEMI for a retrospective study. Twelve‐lead ECGs were obtained to measure P‐wave parameters in diagnosis of ATMI. P‐wave parameters and PR‐segment displacement were compared in patients with and without ATMI.

Results

In inferior leads, PWD and PWDisp were significantly longer in the ATMI group than in the non‐ATMI group (limb lead II, 109.79 ±15.51 ms and 86.65 ±5.02 ms, respectively; P < 0.001; limb lead III, 108.31 ±12.51 ms and 85.27 ±7.47 ms, P < 0.001; aVF, 106.49 ±13.68 ms and 83.01 ±7.89 ms, P < 0.001; PWDisp, 41.67 ±10.72 ms and 25.18 ±5.17 ms, P < 0.001). By contrast, PWA was significantly lower in the ATMI group than in the non‐ATMI group (limb lead II, 0.96 ±0.18 mV and 1.39 ±0.22 mV, respectively; P < 0.001; limb lead III, 0.90 ±0.11 and 1.21 ±0.23, P < 0.001; aVF, 0.88 ±0.17 and 1.26 ±0.28, P < 0.001). PR‐segment displacement was found in 8 (20.5%) patients with ATMI. A PWD ≥95.5 ms in lead DII diagnosed ATMI with a higher sensitivity and specificity (90%, 94%) than did PWA or PWDisp.

Conclusions

This study suggests P‐wave parameters might be considered ECG findings in diagnosis of ATMI in patients with inferior STEMI.     

Thrombus aspiration in late presenters with ST‐elevation myocardial infarction: A single‐center randomized trial

Objectives

To examine whether routine thrombus aspiration (TA) is associated with improved myocardial salvage in patients with ST‐elevation myocardial infarction (STEMI) presenting ≥12 h after onset of symptoms.

Background

TA is a recognized treatment option in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) especially in the setting of heavy thrombus burden. However, data on the role of TA in STEMI patients presenting late after onset of symptoms are limited.

Methods

In this single‐center prospective randomized study, patients with subacute STEMI presenting ≥12 and ≤48 h after symptom onset were randomized to primary PCI with or without manual TA in a 1:1 ratio. The primary endpoint was the myocardial salvage index assessed with Single Photon Emission Computed Tomography (SPECT) on admission and 4 days later.

Results

A total of 60 patients underwent randomization. Baseline characteristics were comparable between groups. TA was associated with improved myocardial salvage index compared with control group (60.1 ± 11.1% vs 28.1 ± 21.3%; P = <0.001). Furthermore, TA was associated with improved post‐procedural TIMI flow (2.9 ± 0.3 vs 2.5 ± 0.6; P = 0.003), myocardial blush grade (2.9 ± 0.3 vs 2.2 ± 0.8, P = <0.001), and reduction in left ventricular end‐diastolic dimensions (50.4 ± 4.3 mm vs 54.4 ± 5.8 mm, P = 0.004) compared with the control group. Clinical outcomes at 30 days and 6 months were similar between both groups.

Conclusions

TA might be associated with improved reperfusion and myocardial salvage especially in STEMI patients presenting after 12 h from symptom onset who are likely to have a heavy thrombus burden.

     

Quality improvement in the door‐to‐balloon times for ST‐elevation myocardial infarction patients presenting without chest pain

Objective: To assess a quality improvement initiative aimed at minimizing door‐to‐balloon (DTB) times for ST‐elevation myocardial infarction (STEMI) patients presenting without chest pain. Background: Timely percutaneous coronary intervention (PCI) is the cornerstone of STEMI care. The absence of chest pain delays PCI. Improvements in DTB times may need to focus on atypical presentation patients. Methods: We compared DTB times on all STEMI patients admitted through the emergency department who underwent PCI before (Phase I; October 2004–June 2007) and after (Phase II; July 2007–October 2009) the quality improvement effort, which mandated rapid electrocardiogram (ECG) triage for an expanded list of presenting symptoms. Results: In Phase I (69 patient, 60 with chest pain), patients with chest pain had a shorter mean time to first ECG (ECG Interval) by 32.0 min (P < 0.01) and nonsignificantly faster mean DTB time by 42.0 min (P = 0.07) compared to patients who presented without chest pain. In Phase II (62 patients, 56 with chest pain) compared to Phase I, mean ECG interval decreased by 44 min (P = 0.02) and mean DTB time by 99 min (P = 0.01) in patients without chest pain, eliminating the differences in ECG intervals between typical and atypical presentations (12 min vs. 11 min, P = 0.91). Multivariable analysis controlling for on/off hours and patient characteristics confirmed these findings. Conclusions: A simple modification of emergency room ECG triage protocol, which expands indications for rapid ECG performance, was successful in improving rapid reperfusion for patients with STEMI presenting without chest pain. © 2011 Wiley‐Liss, Inc.     

Staged versus index procedure complete revascularization in ST‐elevation myocardial infarction: A meta‐analysis

Background

Complete revascularization of patients with ST‐elevation myocardial infarction and multivessel coronary artery disease reduces adverse events compared to infarct‐related artery only revascularization. Whether complete revascularization should be done as multivessel intervention during index procedure or as a staged procedure remains controversial.

Method

We performed a meta‐analysis of randomized controlled trials comparing outcomes of multivessel intervention in patients with ST‐elevation myocardial infarction and multivessel coronary artery disease as staged procedure versus at the time of index procedure. Composite of death or myocardial infarction was the primary outcome. Mantel‐Haenszel risk ratios were calculated using random effect model.

Results

Six randomized studies with a total of 1126 patients met our selection criteria. At a mean follow‐up of 13 months, composite of myocardial infarction or death (7.2% vs 11.7%, RR: 1.66, 95%CI: 1.09‐2.52, P = 0.02), all cause mortality (RR: 2.55, 95%CI: 1.42‐4.58, P < 0.01), cardiovascular mortality (RR: 2.8, 95%CI: 1.33‐5.86, P = 0.01), and short‐term (<30 days) mortality (RR: 3.54, 95%CI: 1.51‐8.29, P < 0.01) occurred less often in staged versus index procedure multivessel revascularization. There was no difference in major adverse cardiac events (RR: 1.14, 95%CI: 0.88‐1.49, P = 0.33), repeat myocardial infarction (RR: 1.14, 95%CI: 0.68‐1.92, P = 0.61), and repeat revascularization (RR: 0.92, 95%CI: 0.66‐1.28, P = 0.62).

Conclusion

In patients with ST‐elevation myocardial infarction and multivessel coronary artery disease, a strategy of complete revascularization as a staged procedure compared to index procedure revascularization results in reduced mortality without an increase in repeat myocardial infarction or need for repeat revascularization.

     

Comparison of procedural times,success rates,and safety between left versus right radial arterial access in primary percutaneous coronary intervention for acute ST‐segment elevation myocardial infarction

Objective: To evaluate if there are differences in procedural times, success rates, and safety between left and right radial approach (LRA and RRA, respectively) in primary percutaneous coronary intervention (PCI) for ST‐elevation myocardial infarction (STEMI). Background: Given conflicting reports of different procedural success with LRA vs. RRA, it is unclear if the side of radial access impacts in‐room procedural times and success rates in primary PCI. At our institution the LRA has been commonly used in certain STEMI patients. Our clinical database was reviewed to see if routine use of the LRA could generate favorable technical success and reperfusion times as compared to the RRA. Methods: We retrospectively analyzed 135 consecutive STEMI patients treated with primary PCI performed via the left and right radial approach at our institution. Results: There were 50 cases in the LRA group and 85 in the RRA group. There was no difference in median procedural times including total procedure time (LRA 53.5 mins vs. RRA 52 mins, P = 0.95), room‐to‐cannulation (LRA 12 min vs. RRA 13 min, P = 0.40) or room‐to‐balloon times (LRA 30 min vs. RRA 31 min, P = 0.74). There were no significant differences in procedural success rates (LRA 100% vs. RRA 97.6%, P = 0.27), or procedure‐related complications or death between the two groups. Conclusions: Left and right trans‐radial approach for primary PCI have similar in room procedural times, success rates, and comparable safety. Trans‐radial PCI through either arm is a feasible and safe approach in patients with STEMI. © 2010 Wiley‐Liss, Inc.