Pre-hospital diagnosis of myocardial infarction: an opportunity to improve outcomes?

Ortolani et al.¹ report on the potential impact of pre-hospitaldiagnosis of ST-elevation myocardial infarction (STEMI). Theauthors compared the different routes of referral taken by patientswho were transferred for primary percutaneous coronary intervention(PCI). A total of 658 STEMI patients were studied and threepredefined referral routes were compared: pre-hospital diagnosisand direct transportation (for patients within 90 min driveof the PCI centre, n=166), diagnosis at the interventional hospitalemergency department (n=316), or diagnosis at local hospitalsbefore transportation (n=176). The main finding of the studywas that patients who had a pre-hospital paramedic and doctorwith telemedicine transmission of STEMI and direct transferfor primary PCI had a significant reduction in ‘treatmenttime’ (from onset of     

急诊介入治疗合并院前心脏骤停急性心肌梗死疗效观察

目的 评价急诊经皮冠状动脉介入治疗(PCI)合并院前心脏骤停急性ST段抬高型心肌梗死(STEMI)的临床疗效.方法 入选2004年9月至2008年11月接受急诊PCI的STEMI患者1446例,其中合并院前心脏骤停患者(心脏骤停组)49例,无院前心脏骤停患者(无心脏骤停组)1397例.分析患者住院期间和出院后1年的临床情况,包括总病死率、心脏不良事件、卒中及出血事件等.结果 与无心脏骤停组比较,心脏骤停组急诊PCI成功率差异无统计学意义(88.8%比85.7%,P=0.497),住院期间心原性休克(3.0%比22.4%,P＜0.001)和心脏骤停(5.9%比44.9%,P＜0.001)的发生率较高,住院期间总病死率较高(2.0%比36.7%,P＜0.001).发病至院外抢救时间、心脏骤停时心律为心室停顿、入院时Glasgow昏迷评分≤7分和人院时心原性休克是心脏骤停组患者住院期间死亡的独立危险因素.随访1年显示,无心脏骤停组与心脏骤停组总病死率(6.5%比6.9%)、再次心肌梗死(1.4%比3.4%)、再次血运重建(3.4%比6.9%)和卒中发生率(6.4%比6.9%)差异均无统计学意义.结论 与无院前心脏骤停STEMI患者比较,合并院前心脏骤停STEMI患者住院期间病死率较高,但是急诊PCI后1年的疗效相似.     

Usefulness of prehospital triage in patients with cardiogenic shock complicating ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

We investigated the impact of ambulance-based prehospital triage on treatment delay and all-cause mortality (in hospital and long term) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock referred for primary percutaneous coronary intervention in a prospectively collected registry. During the study period (January 2003 to December 2005), a total of 121 patients was referred for primary percutaneous coronary intervention at our intervention laboratory through 2 main triage groups: (1) after prehospital, ambulance-telemedicine-based triage (42 patients) and (2) by more conventional routes (79 patients) represented by the institutional S. Orsola-Malpighi hospital emergency department triage (44 patients) and spoke hospital triage (35 patients). Total ischemic time was shorter in the prehospital triage (142 minutes, range 106 to 187, vs 212 minutes, range 150 to 366, p = 0.003). Patients with prehospital triage showed a lower rate (29% vs 54%, p = 0.01) of severely depressed (相似文献   

Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutanous coronary intervention.

AIMS: The majority of patients with ST-elevation myocardial infarction (STEMI) are admitted to local hospitals without primary percutaneous coronary intervention (primary PCI) facilities. Acute transferral to an interventional centre is necessary to treat these patients with primary PCI. The present study assessed the reduction in treatment delay achieved by pre-hospital diagnosis and referral directly to an interventional centre. METHODS AND RESULTS: Two local hospitals without primary PCI facilities were serving the study region. Pre-hospital diagnoses were established with the use of telemedicine, by ambulance physicians, or by general practitioners. Primary PCI was accepted as the preferred reperfusion therapy in patients with STEMI. From 31 October 2002 to 31 January 2004 all patients transported by ambulance and transferred for primary PCI were registered. Patients with STEMI were divided into three groups: (A) patients diagnosed at a local hospital (n = 55), (B) patients diagnosed pre-hospitally and admitted to a local hospital (n = 85), and (C) patients diagnosed pre-hospitally and referred directly to the interventional centre (n = 21). When comparing group A with group B and C, no difference was found in age, sex, infarct location, or distance from the scene of event to the interventional centre, whereas the median time from ambulance call to first balloon inflation was 41 min shorter in group B compared with group A (P<0.001) and 81 min shorter in group C compared with group A (P<0.001). CONCLUSION: In a cohort of patients scheduled for admission to a local hospital and subsequent transferral to an interventional centre for primary PCI, those diagnosed pre-hospitally had shorter treatment delay compared with those diagnosed in hospital, both in the setting of initial admission to a local hospital, and to an even larger extent in the setting of referral directly to the interventional centre.     

急性心肌梗死患者直接经皮冠状动脉介入术后院内死亡的预测因素

目的分析急性心肌梗死(AMI)患者直接PCI术后发生院内死亡的预测因素,以寻找进一步改善AMI患者住院期间预后的可能途径。方法根据314例接受直接PCI的AMI患者住院期间存活与否,将其分为死亡组(26例)和非死亡组(288例),比较两组患者的临床和冠状动脉造影特点,确定发生院内死亡的预测因素。结果死亡组患者中女性(P=0.017)、年龄>75岁(P=0.004)、3支血管病变(P=0.015)、左主干闭塞(P=0.036)、就诊至球囊扩张时间>90min(P=0.013)、并发心源性休克(P=0.000)显著高于非死亡组患者;而PCI成功(P=0.000)、ST段下降>50%(P=0.000)显著低于非死亡组患者。多因素分析显示,心源性休克(P=0.000)、女性(P=0.029)、就诊至球囊扩张时间>90min(P=0.035)是发生院内死亡的独立预测因素。结论为进一步改善接受直接PCI的AMI患者住院期间的预后,未来治疗的重点在于降低高危(特别是心源性休克)患者的病死率,缩短就诊至球囊扩张时间,以及改善冠状动脉微循环和提高心肌水平的再灌注。     

Effectiveness and safety of routine primary angioplasty in patients aged > or =85 years with acute myocardial infarction

BACKGROUND: Although octogenarians constitute a fast growing portion of cardiovascular patients, few data are available on the outcome of very old patients (age >80 years) with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. METHODS AND RESULTS: Short- and long-term outcomes of 88 consecutive very old (age > or =85 years) patients with STEMI undergoing primary angioplasty were evaluated. In-hospital mortality was 17%, significantly higher in patients with cardiogenic shock (90%; p<0.001), with failure of percutaneous coronary intervention (PCI; p=0.016), with Killip class > or =III on admission (p=0.018), or with chronic renal failure (p=0.033). Major bleeding complications occurred in 11 patients (12%). Multivariable logistic regression analysis identified 3 independent predictors of in-hospital death: age > or =90 years (p=0.018), Killip > or =III on admission (p=0.018), and PCI failure (p=0.025). Multivariable logistic regression analysis identified age > or =90 years (p=0.008), Killip > or =III on admission (p=0.015), and time from symptoms to PCI >12 h (p=0.04) as independent predictors of mortality at long-term follow-up. CONCLUSIONS: The low incidence of procedural complications, together with good long term survival, suggest that primary PCI in STEMI patients > or =85 years is safe and efficacious, with a low rate of PCI failure in the presence of a low Killip class on admission, whereas primary PCI is unable to affect the poor prognosis for very old patients with cardiogenic shock.     

影响ST段抬高心肌梗死患者再灌注决定延迟的因素

目的 调相急性ST段抬高心肌梗死(STEMI)患者的再灌注决定延迟程度并分析其影响因素.方法 本研究为多中心现况调查.入选2006年1月1日至12月31日期间就诊于北京市19所医院并接受心肌再灌注治疗的635例急性STEMI患者.入院1周内,通过与患者进行结构式访谈及查阅病例记录收集资料.再灌注决定延迟定义为院内完成首份心电图至患者或家属签署治疗同意书的时间间隔.根据再灌注决定延迟时间分为早决定组(≤30 min)和晚决定组(＞30 min),采用单凶素和多因素分析识别影响再灌注决定延迟的相关凶素.结果 接受溶栓者129例(20.3%),接受直接PCI者506例(79.7%).中位再灌注决定延迟时间为47 min,中位进门-溶栓时间为82 min,中位进门-球囊扩张时间为135 min.多元logistic回归分析显示,了解再灌注治疗(OR=1.723,95%CI:1.156～3.212,P=0.040)、有院前心电图(OR=1.566,95% CI:1.018～2.409,P=0.036)、入院时心功能Killip分级≥2(OR=1.579,95% CI:1.004～2.483,P=0.021)以及就诊于心血管专科医院(OR=5.075,95%CI:1.380～18.655,P=0.014)是再灌注决定延迟≤30 min的独立预测因素.早决定组的中位进门-溶栓时间(47 min比103 min,P＜0.001)和中位进门-球囊扩张时间(100 min比154min,P＜0.001)明显短于晚决定组.结论 STEMI的再灌注决定延迟时间偏长,是院内延迟的主要部分.普及再灌注治疗知识以及通过救护车转运增加院前心电图完成率可能缩短院内延迟.     

Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

Background

Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.

Impact of COVID-19 on Outcomes of Patients Hospitalized With STEMI: A Nationwide Propensity-matched Analysis

Patients with ST-segment elevation myocardial infarction (STEMI) and concurrent coronavirus disease 2019 (COVID-19) have been reported to have poor outcomes. However, previous studies are small and limited. The National Inpatient Sample database for the year 2020 was queried to identify all adult hospitalizations with a primary diagnosis of STEMI, with and without concurrent COVID-19. A 1:1 propensity score matching was performed. A total of 159,890 hospitalizations with a primary diagnosis of STEMI were identified. Of these, 2210 (1.38%) had concurrent COVID-19. After propensity matching, STEMI patients with concurrent COVID-19 had a significantly higher mortality (17.8% vs 9.1%, OR 1.96, P< 0.001), lower likelihood to receive same-day percutaneous coronary intervention (PCI) (63.6% vs 70.6%, P = 0.019), with a trend towards lower overall PCI (74.9% vs 80.2%, P = 0.057) and significantly lower coronary artery bypass grafting) (3.0% vs 6.8%, P = 0.008) prior to discharge, compared with STEMI patients without COVID-19. The prevalence of cardiogenic shock, need for mechanical circulatory support, extracorporeal membrane oxygenation, cardiac arrest, acute kidney injury (AKI), dialysis, major bleeding and stroke were not significantly different between the groups. COVID-19-positive STEMI patients who received same-day PCI had significantly lower odds of in-hospital mortality (adjusted OR 0.42, 95% CI 0.20-0.85, P = 0.017). STEMI patients with concurrent COVID-19 infection had a significantly higher (almost 2 times) in-hospital mortality, and lower likelihood of receiving same-day PCI, overall (any-day) PCI, and CABG during their admission, compared with STEMI patients without COVID-19.     

急性心肌梗死合并心原性休克患者住院期间结果及影响因素分析

目的探讨影响急性心肌梗死(AMI)合并心原性休克(CS)患者住院期间死亡的因素。方法回顾性分析2002年4月至2019年4月于首都医科大学附属北京朝阳医院心脏中心接受治疗的321例AMI合并CS患者的临床资料。将患者分为院内死亡组(230例)和院内生存组(91例)。比较两组患者的基线特征、冠状动脉造影和介入治疗特征、心功能和生化指标。结果与院内生存组相比,院内死亡组患者年龄偏大,院前时间偏长,非ST段抬高型心肌梗死比例偏高;三支冠状动脉病变发生率高,实施心肺复苏比例高,急诊经皮冠状动脉介入治疗(PCI)率偏低;血清肌酐和B型脑钠肽显著增高。两组主动脉内球囊反搏(IABP)置入率相当(82.3%比86.8%,P=0.349)。两组左心室射血分数、肌钙蛋白I峰值、低密度脂蛋白胆固醇、白细胞计数、红细胞沉降率和C反应蛋白比较,差异均无统计学意义(均P>0.05)。logistic多因素回归分析显示,年龄(OR 1.005,95%CI 0.992~1.212,P=0.047)、院前时间(OR 0.898,95%CI 0.991~1.006,P=0.048)、急诊PCI(OR 0.331,95%CI 0.103~3.521,P=0.039)和实施心肺复苏(OR 7.238,95%CI 1.620~32.343,P=0.010)是AMI合并CS住院期间死亡的独立预测因素。结论IABP置入不影响AMI合并CS住院期间生存率。年龄、院前时间、急诊PCI和实施心肺复苏是住院期间死亡的独立预测因素。     

Prognostic value of admission hemoglobin levels in ST-segment elevation myocardial infarction patients presenting with cardiogenic shock

Even in the era of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), mortality remains high. Whether admission hemoglobin (Hb) concentration is a predictor of mortality in patients with CS treated with primary PCI is unexplored. We assessed the relation between admission Hb concentration and 1-year mortality in patients with STEMI and CS who were treated with PCI at admission. We investigated a cohort of 265 patients with STEMI with CS on admission. Patients were categorized in 3 groups according to plasma Hb levels at admission: 9.6 g/dl (group I, n = 22), 9.6 to 12 g/dl (group II, n = 59), and >12 g/dl (group III, n = 184). All-cause mortality at 1 year was 64%, 46%, and 35% for groups I, II, and III, respectively (p = 0.007). Multivariate logistic regression analysis showed that the odds for mortality increased 17% for every 1.0 g/dl decrease in plasma Hb (odds ratio 1.17, 95% confidence interval 1.01 to 1.35, p = 0.042). In conclusion, admission Hb concentration is an independent predictor for 1-year mortality in patients with STEMI undergoing primary PCI.     

Percutaneous coronary intervention for cardiogenic shock in the SHOCK Trial Registry

BACKGROUND: The SHOCK Registry prospectively enrolled patients with cardiogenic shock complicating acute myocardial infarction in 36 multinational centers. METHODS: Cardiogenic shock was predominantly attributable to left ventricular pump failure in 884 patients. Of these, 276 underwent percutaneous coronary intervention (PCI) after shock onset and are the subject of this report. RESULTS: The majority (78%) of patients undergoing angiography had multivessel disease. As the number of diseased arteries rose from 1 to 3, mortality rates rose from 34.2% to 51.2%. Patients who underwent PCI had lower in-hospital mortality rates than did patients treated medically (46.4% vs 78.0%, P < .001), even after adjustment for patient differences and survival bias (P = .037). Before PCI, the culprit artery was occluded (Thrombolysis In Myocardial Infarction grade 0 or 1 flow) in 76.3%. After PCI, the in-hospital mortality rate was 33.3% if reperfusion was complete (grade 3 flow), 50.0% with incomplete reperfusion (grade 2 flow), and 85.7% with absent reperfusion (grade 0 or 1 flow) (P < .001). CONCLUSIONS: This prospective, multicenter registry of patients with acute myocardial infarction complicated by cardiogenic shock is consistent with a reduction in mortality rates as the result of percutaneous coronary revascularization. Coronary artery patency was an important predictor of outcome. Measures to promote early and rapid reperfusion appear critically important in improving the otherwise poor outcome associated with cardiogenic shock.     

Predictors of survival after contemporary percutaneous coronary revascularization for acute myocardial infarction in the real world

Management strategies for ST-elevation myocardial infarction (STEMI) have undergone great evolution over the past decade. The objectives of this study were to evaluate the in-hospital and long-term clinical outcomes, as well as predictors of survival, among patients who received the most contemporary percutaneous coronary revascularization strategies for STEMI in real clinical practice. During the period from October 1, 2000 to April 30, 2002, 316 patients have undergone primary percutaneous coronary intervention (PCI) in a tertiary University hospital, the in-hospital (11.1%), 30-day (13.9%) and long-term (21.8%) mortality rates were higher than that reported in randomized studies. This is likely to be due to the higher prevalence of adverse clinical profiles. Multivariable analysis show that age >65, cardiogenic shock, resuscitated cardiac arrest and intubation independently predicted in-hospital and long-term mortality, while multi-vessel disease predicted major adverse cardiac event (MACE). Among patients with cardiogenic shock, similar mortality was observed in patients with anterior myocardial infarction (MI) or inferior MI with/without right ventricle involvement.     

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

IntroductionPatients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.ObjectivesTo assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.MethodsWe performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.ResultsMedian DIDO time was 82 min (interquartile range, 61–132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062–1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).ConclusionA DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.     

Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention

OBJECTIVE: To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI). METHODS: Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004. RESULTS: The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004). CONCLUSION: In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.     

Prospective evaluation of early abciximab and primary percutaneous intervention for patients with ST elevation myocardial infarction complicated by cardiogenic shock: results of the REO-SHOCK trial

OBJECTIVE: Patients with acute myocardial infarction complicated by cardiogenic shock have a high mortality despite the use of early reperfusion therapies with thrombolysis or percutaneous coronary intervention (PCI). Therefore, there is still need to evaluate therapy strategies in these patients. DESIGN: The REO-SHOCK trial was a prospective, non-randomized study, aimed at evaluation of a routine strategy of early abciximab and PCI in a high-risk group of acute ST elevation myocardial infarction (STEMI) patients with cardiogenic shock. RESULTS: Patients (n = 40) planned for coronary angioplasty or stenting received abciximab (0.25 mg/kg bolus followed by 0.125 mg/kg/minute over 12 hours), heparin and aspirin. The intervention was successful in 92.5% of the patients and achieved Thrombolysis In Myocardial Infarction (TIMI) grade 3 patency in 32 patients (80%). The primary endpoint, total mortality after 30 days, was observed in 42.5% (17/40), and was significantly different between patients aged > 75 years and patients aged 75 years (91% versus 24%, respectively; p < 0.001). Major bleeding occurred in 2 patients (5%), but stroke occurred in none. CONCLUSION: A strategy of abciximab with primary PCI in high-risk patients with cardiogenic shock is safe, associated with a high procedural success rate and seems to improve outcomes in patients < 75 years old.     

Results of primary percutaneous coronary intervention in a consecutive group of patients with acute ST elevation myocardial infarction at a tertiary Australian centre

Background: Multicentre randomized controlled trials (RCT) of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) have consistently shown lower mortality compared with fibrinolysis, if carried out in a timely manner. Although primary PCI is now standard of care in many centres, it remains unknown whether results from RCT of selected patients are generalizable to a ‘real‐world’ Australian setting. The primary goal of this study was to evaluate whether a strategy of routine invasive management for patients with STEMI can achieve 30‐day and 12‐month mortality rates comparable with multicentre RCT. Secondary goals were to determine 30‐day mortality rates in prespecified high‐risk subgroups, and symptom‐onset‐ and door‐to‐balloon‐inflation times. Methods: A retrospective observational study of 189 consecutive patients treated with primary PCI for STEMI in a single Australian centre performing PCI for acute STEMI. Results: All‐cause mortality was 6.9% at 30 days, and 10.4% at 12 months. Mortality in patients presenting without cardiogenic shock was low (2.4% at 30 days; 5.0% at 12 months), whereas 12‐month mortality in patients with shock was higher, particularly in the elderly (29.4% for patients <75 years; 85.7% for patients ≥75 years, P = 0.01). Symptom‐onset‐to‐balloon‐inflation time was ≤4 h in 56% of patients (median 231 min); however, a door‐to‐balloon time of <90 min was achieved in only 20% (median 133 min). Conclusion: Mortality and symptom‐onset‐to‐balloon‐inflation times reported in RCT of primary PCI for STEMI are generalizable to ‘real‐world’ Australian practice; however, further efforts to reduce door‐to‐balloon times are required.     

Comparison of outcome in patients with ST-elevation versus non-ST-elevation acute myocardial infarction treated with percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are increasingly being treated with percutaneous coronary intervention (PCI) and we sought to determine risk of adverse outcomes by type of MI. Patients enrolled in the National Heart, Lung, and Blood Institute Dynamic Registry from 1999 to 2004 who presented with an acute MI as an indication for PCI were studied. Baseline data and in-hospital and 1-year outcomes were compared based on ST-segment elevation (STEMI, n = 903; NSTEMI, n = 583) at presentation. Patients with STEMI were younger, had fewer co-morbidities, and had less extensive coronary artery disease than did patients with NSTEMI. Angiographic success and periprocedural complications were similar by MI type. In-hospital coronary artery bypass grafting, stroke, bleeding and recurrent MI were similar but mortality was higher in patients with STEMI (4.0% vs 1.4%, p = 0.004). Cardiogenic shock was associated with the greatest risk of in-hospital death (odds ratio 26.7, 95% confidence interval 11.4 to 62.3, p = 0.0001), but STEMI was also independently predictive of mortality. At 1 year, there was no influence of MI type on outcome. Age, cardiogenic shock, renal disease, peripheral vascular disease, and cancer were predictive of death and MI. Multivessel disease and a larger number of >50% lesions were associated with the need for repeat revascularization. In conclusion, STEMI was associated with a higher likelihood of in-hospital death than was NSTEMI, but long-term outcomes after PCI were independent of MI type. At 1 year, associated co-morbidities were strongly associated with death and MI, whereas only angiographic characteristics predicted the need for repeat revascularization.     

Impact of atrial fibrillation on the no-flow phenomenon during primary percutaneous coronary intervention

Background Atrial fibrillation(AF)is reported to be associated with worse flow in patients with the treatment of coronary thrombolysis. However,few studies investigated the impact of atrial fibrillation on the noreflow phenomenon in ST-segment elevation myocardial infarction(STEIMI)patients undergoing primary percutaneous intervention(PCI). Methods 1163 STEMI patients undergoing primary PCI from Jan 2013 to Dec2019 were enrolled. Atrial fibrillation was diagnosed based on the electrocardiogram's findings. Patients with a TIMI flow rate less than 3 were considered to have no-reflow. Factors related to the no-reflow phenomenon was analyzed by the logistic regression analysis. Results 158 patients were in the AF group and 1005 patients were in the non-AF group. The AF group had a significantly higher occurrence of cardiogenic shock(11.4% vs. 5.6%,P0.001),and in-hospital mortality(9.5% vs. 3.1%,P0.001)than the non-AF group. The multivariate analysis showed that AF was an independent risk factor for the no-reflow phenomenon after primary PCI(OR:2.11,95% CI:1.27-3.88,P=0.014). Conclusions STEMI patients with AF would have higher in-hospital adverse events and no-reflow phenomenon than though without AF.[S Chin J Cardiol 2020;21(2):98-103]     

Relationship between blood glucose on admission and prognosis in patients with acute myocardial infarction treated with percutaneous coronary intervention

BACKGROUND: Diabetes mellitus in patients with myocardial infarction affects in-hospital and late mortality. It has been shown that the glucose level on admission can also affect prognosis. This conclusion was based on an analysis performed on a heterogeneous group of patients, treated not only with percutaneous coronary intervention (PCI) but also with fibrinolysis. Moreover, the threshold values hyperglycaemia for the diagnosis of were also variable. AIM: To assess whether glucose level on admission affects in-hospital and one-year prognosis in patients with ST-segment elevation myocardial infarction (STEMI) treated with PCI. METHODS: Consecutive patients with STEMI treated with PCI were included in the analysis. Patients with STEMI complicated by cardiogenic shock were also included. Three groups according to the glucose level on admission were analysed: group I - <7.8 mmol/l (140 mg/dl), group II - 7.8-11.1 mmol/l (140-200 mg/dl), and group III - > or = 11.1 mmol/l (200 mg/dl). RESULTS: The incidence of diabetes mellitus in the total group (1027 patients) was 26.1%, and of cardiogenic shock - 9.2%. Group I consisted of 472 patients, group II - 307 patients, and group III - 248 patients. Compared with normoglycaemic patients, those with elevated glucose level were older, more often female, had more often hypertension, diabetes mellitus, cardiogenic shock, were more often treated with fibrinolysis before PCI but were less often smokers. Multivessel disease and initial patency of the infarct-related artery (TIMI 0-1) were more often observed in patients with higher glucose level. A trend towards a higher incidence of reocclusion was also more often present in patients with increased glucose level. Moreover, mean creatine kinase concentration was the highest and the left ventricular ejection fraction was the lowest in group III. During the in-hospital stay, the complication rate was as follows: stroke (1.1% vs. 1.3% vs. 4.4%), and mortality (2.8 vs. 4.9 vs. 13.3%) in groups I, II, and III, respectively. The same tendency was observed during the one-year follow-up period: stroke (1.3 vs. 2.9 vs. 6.9%), mortality (6.4 vs. 9.1 vs. 22.6%). The 1 mmol/l (18 mg/dl) increase of the baseline glucose level among various risk factors was an independent prognostic factor of higher -year mortality (HR=1.06; 95% CI 1.02-1.09). Diabetes mellitus did not affect prognosis among patients included in the analysis. CONCLUSION: Elevated glucose level on admission is associated with adverse prognosis in patients with STEMI treated with PCI.