Angiographically evident thrombus following fibrinolytic therapy is associated with impaired myocardial perfusion in STEMI: a CLARITY-TIMI 28 substudy.

AIMS: The presence of residual thrombus following fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) may predispose to greater embolization and microvascular dysfunction. METHODS AND RESULTS: We hypothesized that even in the presence of a patent epicardial artery, residual thrombus would be associated with worsened TIMI myocardial perfusion grades (TMPG), independent of epicardial flow. Data were analysed from the angiograms of 2684 patients enrolled in the CLARITY-TIMI 28 trial, with angiographically patent arteries (TIMI 2/3 flow) at a median of 88 h following fibrinolytic therapy. Thrombus in a patent epicardial artery was observed more frequently among patients with shorter times from randomization to angiography, among patients with non-left anterior descending infarctions, and among patients treated with placebo (vs. clopidogrel). Thrombus was associated with more frequent TIMI 2 flow (35.1 vs. 22.1%, P < 0.001), higher corrected TIMI frame counts (CTFC) (42 vs. 33 frames, P < 0.001), and a lower incidence of normal TMPG 3 (48.7 vs. 63.9%, P < 0.001), irrespective of treatment with clopidogrel or placebo. In multivariable analyses, thrombus remained associated with higher CTFC (P < 0.001) and worse TMPG (OR 1.6 for TMPG 0/1/2, P < 0.001) after adjustment for baseline covariates as well as known correlates of TMPG. The association between thrombus and impaired TMPG remained even after further adjustment for CTFC or TIMI flow grade. CONCLUSION: Residual angiographic thrombus following fibrinolytic therapy in STEMI patients is associated with impaired myocardial perfusion, independent of epicardial flow. This finding emphasizes the roles of platelet aggregation and distal embolization in the pathogenesis of microvascular dysfunction in STEMI.     

Usefulness of universal beta-blocker therapy in patients after ST-elevation myocardial infarction

The use of beta-blockers (BB) in the context of ST-segment elevation myocardial infarction (STEMI) was a universal practice in the pre-reperfusion era. Since then, evidence of their use for secondary prevention after STEMI is scarce. Our aim is to determine treatment results associated with BB therapy after a STEMI at 1-year follow-up in a contemporary nationwide cohort.A prospective analysis involving 49 national centers, including patients admitted with STEMI, enrolled between October 2010 and September 2019 was conducted. The primary outcome was defined as the composite of all-cause mortality or hospital re-admission for a cardiovascular (CV) cause in the first year after STEMI. The patients were distributed into 2 groups, depending on whether they received therapy with BB at hospital discharge or not (BB and NB group, respectively).A total of 3145 patients were included in the analysis, of which 2526 (80.3%) in the BB group. A total of 12.2% of patients reached the primary outcome. Regarding the univariate Cox regression analysis, the BB group presented lower mortality or re-admission for CV cause at 1-year follow-up [hazard ratio (HR) 0.69, confidence interval (CI) 95% 0.55–0.87, P = .001]. However, after adjustment for significant covariates, this association was lost (HR 0.73, CI 95% 0.51–1.04, P = .081). In patients with preserved (HR 0.73, CI 95% 0.51–1.04, P = .081) and mid-range (HR 1.01, CI 95% 0.64–1.61, P = .959) left ventricular ejection fraction (LVEF), the primary outcome was similar between the 2 groups, while in patients with reduced LVEF, the BB group presented a better prognosis, with fewer patients reaching the primary outcome (HR 0.431, CI 95% 0.262–0.703, P = .001).BB universal therapy after STEMI has not proved useful, but it seems to be beneficial in patients with reduced LVEF.     

Assessment of myocardial perfusion with thallium-201 scintigraphy in exercise-induced left bundle branch block: diagnostic value and clinical significance.

Myocardial perfusion scintigraphy with thallium-201 was performed in 33 subjects (mean age 45 years, range 28-61) with exercise-induced, rate-dependent left bundle branch block (LBBB) in order to assess both the value of Thallium-201 myocardial imaging for the diagnosis of coronary artery disease (CAD) and the pathogenesis (ischaemic or not) of the conduction defect. Of the 33 patients evaluated, 16 had chest pain suggestive of CAD and 17 were asymptomatic. None had a history of prior myocardial infarction or clinical and echocardiographic signs of heart disease. LBBB appeared at a heart rate ranging from 70 to 160 b.min-1. Eighteen patients showed repolarization abnormalities (ST segment depression with deep inverted T waves) compatible with ischaemia, after QRS normalization. Thallium-201 myocardial uptake was normal in 12 subjects; in the remaining 21, reversible Thallium-201 defects were demonstrated in the septum (18 patients), septum and apex (2), and septum and infero-apical wall (1). No patient had irreversible defects and all had normal coronary angiography, with negative ergonovine tests for coronary artery spasm. The patients were followed up for a mean of 43 months (range 16-80). One patient died from sudden death, but no cardiac event occurred in the other patients. In conclusion, exercise Thallium-201 myocardial scintigraphy showed a high prevalence (64%) of reversible perfusion defects in a group of patients with exercise-induced LBBB without any evidence of CAD at angiography or coronary spasm at ergonovine test. Moreover, follow-up showed a relatively low rate of major cardiac events.     

Prognostic value of frontal QRS-T angle in predicting survival after primary percutaneous coronary revascularization/coronary artery bypass grafting for ST-elevation myocardial infarction

BackgroundFrontal QRS-T angle (FQRST) has previously been correlated with mortality in patients with stable coronary artery disease, but its role as survival predictor after ST-elevation myocardial infarction (STEMI) remains unknown.MethodsWe evaluated 267 consecutive patients with STEMI undergoing reperfusion or coronary artery bypass grafting. Data assessed included demographics, clinical presentation, electrocardiograms, medical therapy, and one-year mortality.ResultsOf 267 patients, 187 (70%) were males and most (49.4%) patients were Caucasian. All-cause mortality was significantly higher among patients with the highest (101–180°) FQRST [28% vs. 15%, p = 0.02]. Patients with FQRST 1–50° had higher survival (85.6%) compared with FQRST = 51–100° (72.3%) and FQRST = 101–180° (67.9%), [log rank, p = 0.01]. Adjusting for significant variables identified during univariate analysis, FQRST (OR = 2.04 [95% CI: 1.31–13.50]) remained an independent predictor of one-year mortality. FQRST-based risk score (1–50° = 0 points, 51–100° = 2 points, 101–180° = 5 points) had excellent discriminatory ability for one-year mortality when combined with Mayo Clinic Risk Score (C statistic = 0.875 [95%CI: 0.813–0.937]. A high (>4 points) FQRST risk score was associated with greater mortality (32% vs. 19%, p = 0.02) and longer length of stay (6 vs. 2 days, p < 0.001).ConclusionFQRST represents a novel independent predictor of one-year mortality in patients with STEMI undergoing reperfusion. A high FQRST-based risk score was associated with greater mortality and longer length of stay and, after combining with Mayo Clinic Risk Score, improved discriminatory ability for one-year mortality.     

High triglyceride-glucose index is associated with adverse cardiovascular outcomes in patients with acute myocardial infarction

Background and aimsTriglyceride glucose (TyG) index is considered a new surrogate marker of insulin resistance that associated with the development of vascular disease. The aim of this study was to evaluate the prognostic value of TyG index in patients with acute myocardial infarction (AMI).Methods and resultsA total of 3181 patients with AMI were included in the analysis. Patients were stratified into 2 groups according to their TyG index levels: the TyG index <8.88 group and the TyG index ≥8.88 group. The incidence of major adverse cardiovascular events (MACEs) during a median of 33.3-month follow-up were recorded. Multivariable Cox regression models revealed that the TyG index was positively associated with all-cause death [HR (95% CI): 1.51 (1.10,2.06), p = 0.010], cardiac death [HR (95% CI): 1.68 (1.19,2.38), p = 0.004], revascularization [HR (95% CI): 1.50 (1.16,1.94), p = 0.002], cardiac rehospitalization [HR (95% CI): 1.25 (1.05,1.49), p = 0.012], and composite MACEs [HR (95% CI): 1.19 (1.01,1.41), p = 0.046] in patients with AMI. The independent predictive effect of TyG index on composite MACEs was mainly reflected in the subgroups of male gender and smoker. The area under the curve (AUC) of the TyG index predicting the occurrence of MACEs in AMI patients was 0.602 [95% CI 0.580,0.623; p < 0.001].ConclusionHigh TyG index levels appeared to be associated with an increased risk of MACEs in patients with AMI. The TyG index might be a valid predictor of cardiovascular outcomes of patients with AMI.Trial registrationRetrospectively registered.     

An independent relation of atopic dermatitis to exercise-induced wheezing in asthmatic children

Background

Atopic dermatitis (AD) and exercise-induced asthma (EIA) are common in asthmatic children, and exercise is the most common trigger other than infection for acute onset asthma attack in children. We examined whether AD is related to exercise-induced wheezing (EIW), some proxy for EIA.

Historical perspective and contemporary management of acute coronary syndromes: from MONA to THROMBINS2

Acute coronary syndrome (ACS) remains a major burden on morbidity and mortality in the United States. Medical professionals and students often use the mnemonic ‘MONA’ (morphine, oxygen, nitroglycerin and aspirin) to recall treatments for ACS; however, this list of therapies is outdated. We provide a historical perspective on ‘MONA,’ attempt to uncover its origin in the medical literature, and demonstrate the myriad changes that have occurred over the last 50 years of ACS management. We have developed a novel mnemonic, ‘THROMBINS₂’ (thienopyridines, heparin/enoxaparin, renin–angiotensin system blockers, oxygen, morphine, beta blocker, intervention, nitroglycerin, statin/salicylate) to help bedside clinicians recall all the elements of contemporary ACS management. We demonstrate the mortality benefit for each component of contemporary ACS management, correlating the continued improvement with historical data on mortality after myocardial infarction. We encourage providers to utilize this mnemonic to explore options and guide treatments in ACS patients.     

Human recombinant-B-type natriuretic peptide protect ventricular function and structure in ST-elevation myocardial infarction

Background: ST-elevation myocardial infarction (STEMI) is the most serious clinical type of coronary artery disease (CAD), which will lead to a loss of contractile function asa result of adverse left ventricular (LV) remodeling. Post-myocardial infarction remodeling is detrimental to the left ventricular function, which is strongly related to clinical outcome,including heart failure and cardiac death. And our study was designed toassess the efficacy of 72-hour IV infusion of rh-BNP therapy in STEMI patients with or without successful primary PCI, in preventing adverse LV remodeling and preserving LV function. Methods: 100 patients diagnosed as STEMI combined with acute heart failure (Killip classification ≥2) were recorded. And they were dividedinto “rh-BNPtreatment group” (n=50) and “control group” (n=50). In addition to conventional heart failure therapy, patients in the rh-BNP group receivedrh-BNPinfusion for 72 hours. All patients were followed up at 3 month after discharge. Their medical history was taken, as well as the presence or absence of relevant symptoms. 6-minute walking test, as well as echocardiographic indexes were recorded to evaluate the improvement of cardiac function. Results: The data analysis about demographic comparison, including those related complicated diseases among groups showed no significant difference. After the follow-up, the indicators were all better than baseline among four subgroups (all P<0.001). Results showed that rh-BNP was able to significantly reduce the NT-pro BNP levels (P<0.001), decrease LVESD (P<0.01), and increase LVEF (P<0.05). The difference of 6WMT between two groups was significant (P<0.001). According to the classification of 6WMT, the multivariate Cox regression showed that the usage of rh-BNP was an independent predictor for 6WMT (OR 0.478, 95% CI, 0.290-0.787), while it may not for MACE (OR 1.762, 95% CI, 0.793-3.913). Conclusions: Although the use of rh-BNP was not an independent risk factor in prediction of MACE in our study, the current data still showed that rh-BNP is a useful prognosis factor of 6WMT in the STEMI patients. The protection of ventricular function and structure in STEMI patients is affirmative.     

Correlates and Outcomes of Late and Very Late Drug-Eluting Stent Thrombosis: Results From DESERT (International Drug-Eluting Stent Event Registry of Thrombosis)

ObjectivesThe aim of this study was to identify clinical, procedural, and angiographic correlates of late/very late drug-eluting stent (DES) thrombosis as well as to determine the clinical outcomes of these events.BackgroundLate/very late DES thromboses are a poorly studied phenomenon, partly due to the relative infrequency of these events, even in large cohort studies.MethodsIn the DESERT (International Drug-Eluting Stent Event Registry of Thrombosis), a retrospective, case-control registry, 492 cases of late/very late definite DES thrombosis from 21 international sites were matched in a 1:1 fashion with controls without stent thrombosis (ST). Controls were matched according to 2 criteria: same enrolling institution and date of initial DES implantation. Baseline and procedural variables were collected, and clinical follow-up was obtained for patients with ST as long as 1 year after the event. Offline quantitative coronary angiography was performed for a subset of 378 case-control pairs.ResultsThe majority of ST events occurred after 1 year (75%) and continued to occur for as long as 7.3 years. The clinical presentation of late/very late ST events was mainly myocardial infarction (66.7% ST-segment elevation myocardial infarction and 22.0% non–ST-segment elevation myocardial infarction); in-hospital mortality was 3.8%. A minority of patients (30%) with ST were receiving dual-antiplatelet therapy at the time of the event. Independent clinical correlates of late/very late ST were younger age, African-American race, current smoking, multivessel disease, longer stented length, overlapping stents, and percutaneous coronary intervention of vein graft lesions. Independent angiographic correlates for late/very late ST were lesions within the left anterior descending artery or a bypass graft, thrombus, and a larger residual diameter stenosis after the initial DES implantation. Despite the large sample of ST cases, all identified correlates of late/very late ST had weak associations with subsequent ST (all odds ratios <2.5).ConclusionsDespite a large sample of ST cases and use of limited matching to maximize the identification of predictive factors associated with late/very late ST, the variables associated with the development of late/very late ST were only weakly predictive of subsequent events. Additionally, a relatively low observed mortality rate of ST in this series may reflect a different pathophysiology of these late/very late events compared with acute/subacute ST. (Drug Eluting Stent Registry of Thrombosis [DESERT]; NCT00812552).     

Coronary thrombus in patients undergoing primary PCI for STEMI:Prognostic significance and management

Acute ST-elevation myocardial infarction(STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator,which is mostly proportional to their size and composition. Particularly,intracoronary thrombi impair both epicardial blood flow and myocardial perfusion,by occluding major coronary arteries and causing distal embolization,respectively. Thus,although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting,the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients,by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used inthe setting of STEMI to manage thrombotic lesions.