Five-Year Follow-Up After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis and Concomitant Coronary Artery Disease: A Single-Center Experience

ABSTRACT Introduction: There is no consensus on the impact of coronary artery disease in patients undergoing transcatheter aortic valve implantation. Therefore, the objective of this study was, in a single-center setting, to evaluate the five-year outcome of transcatheter aortic valve implantation patients with or without coronary artery disease. Methods: All transcatheter aortic valve implantation patients between 2009 and 2019 were included and grouped according to the presence or absence of coronary artery disease. The primary endpoint, five-year all-cause mortality, was evaluated using Cox regression adjusted for age, sex, procedure years, and comorbidities. Comorbidities interacting with coronary artery disease were evaluated with interaction tests. In-hospital complications was the secondary endpoint. Results: In total, 176 patients had aortic stenosis and concomitant coronary artery disease, while 170 patients had aortic stenosis only. Mean follow-up was 2.2±1.6 years. There was no difference in the adjusted five-year all-cause mortality between transcatheter aortic valve implantation patients with and without coronary artery disease (hazard ratio 1.00, 95% confidence interval 0.59-1.70, P=0.99). In coronary artery disease patients, impaired renal function, peripheral arterial disease, or ejection fraction < 50% showed a significant interaction effect with higher five-year all-cause mortality. No significant differences in complications between the groups were found. Conclusion: Five-year mortality did not differ between transcatheter aortic valve implantation patients with or without coronary artery disease. However, in patients with coronary artery disease and impaired renal function, peripheral arterial disease, or ejection fraction < 50%, we found significantly higher five-year all-cause mortality.

Characteristics of ST-Elevation Myocardial Infarction during the SARS-CoV-2 Outbreak

Abstract Background The SARS-CoV-2 outbreak has led to radical transformation in social, economic, and healthcare systems. This may lead to profound indirect consequences on clinical presentation and management of patients with ST-segment-elevation myocardial infarction. Objectives The objective of this study was to describe the characteristics, management, and outcomes of patients admitted with acute myocardial infarction with ST-segment elevation (STEMI), in two tertiary reference hospitals during the SARS-CoV-2 outbreak and compare them with patients admitted in the previous year. Methods We analyzed data from a multicenter STEMI registry from reference centers in the South Region of Brazil from March 2019 to May 2021. The beginning of the COVID-19 outbreak was considered to be March 2020 and compared to the same period in 2019. Only patients with STEMI submitted to primary percutaneous coronary intervention (PCI) were included in the analysis. Mortality rates were compared with chi-square test. All hypothesis tests had a two-sided significance level of 5%. Results A total of 1169 patients admitted with STEMI were enrolled in our registry, 635 of whom were admitted during the pandemic period. The mean age of our sample was 61.6 (± 12.4) years, and 66.7% of patients were male. Pain-to-door time and door-to-balloon time were longer during the pandemic period. However, there was no difference in mortality rates or major adverse cardiovascular outcomes (MACE). Conclusions We observed a stable incidence of STEMI cases in our registry during the SARS-CoV-2 outbreak with higher pain-to-door time and door-to-balloon time, without any influence on mortality rates however.

Surgical treatment of Stanford type A aortic dissection after coronary artery stenting / 中国胸心血管外科临床杂志

@#Objective    To retrospectively analyze the surgical treatment of Stanford type A aortic dissection after coronary artery stenting, and to explore the surgical techniques and surgical indications. Methods    Clinical data of 1 246 consecutive patients who underwent operations on Stanford type A aortic dissection from April 2016 to July 2019 in Beijing Anzhen Hospital were retrospectively analyzed. Patients with Stanford type A aortic dissection after coronary artery stenting were enrolled. Results    Finally 19 patients were collected, including 16 males and 3 females with an average age of 54±7 years ranging from 35 to 66 years. There were 11 patients in acute phase, 15 patients with AC (DeBakey Ⅰ) type and 4 patients with AS (DeBakey Ⅱ) type. In AC type, there were 10 patients receiving Sun's surgery and 5 patients partial arch replacement. Meanwhile, coronary artery bypass grafting was performed in 7 patients and mitral valve replacement in 1 patient. Stents were removed from the right coronary artery in 4 patients. In this group, 1 patient died of multiple organ failure in hospital after operation combined with malperfusion of viscera. Eighteen patients recovered after treatment and were discharged from hospital. The patients were followed up for 30 (18-56) months. One patient underwent aortic pseudoaneurysm resection, one thoracic endovascular aortic repair, one emergency percutaneous coronary intervention due to left main artery stent occlusion, and one underwent femoral artery bypass due to iliac artery occlusion. Conclusion    Iatrogenic aortic dissection has a high probability of coronary artery bypass grafting at the same time in patients with Stanford type A aortic dissection after coronary artery stenting. Complicated type A aortic dissection after percutaneous coronary intervention should be treated with surgery aggressively.

Alta temprana en infarto agudo de miocardio con elevación del segmento ST tratado con angioplastia primaria: estudio de intervención no controlado en Argentina / Early Discharge in Acute ST-segment Elevation Myocardial Infarction Treated with Primary Angioplasty: Uncontrolled Intervention Study in Argentina

RESUMEN Introducción y objetivos: El alta hospitalaria temprana (dentro de las primeras 48 horas) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) tratados con angioplastia coronaria primaria con stent (ATCp) ha sido adoptada en países desarrollados. Sin embargo, su implementación en Sudamérica ha sido dispar. Material y métodos: Estudio piloto de intervención no controlado, argentino, de pacientes con IAMCEST de bajo riesgo tratados con ATCp, para evaluar tasa de alta temprana y comparar la incidencia de eventos cardiovasculares adversos mayores (MACE) con la que ocurre en pacientes externados en forma no temprana. Resultados: Desde 2013 hasta 2021 se trataron con ATCp 320 pacientes con IAMCEST, de los que 158 fueron de bajo riesgo. Alta temprana en 63,9% (IC 95% 55,9-71,4%). La diabetes (OR 0,31; IC 95% 0,12-0,83) y el IAMCEST anterior (OR 0,34; IC 95% 0,16-0,69) se asociaron en forma independiente con menor probabilidad de alta temprana. Durante una mediana de seguimiento de 27,2 meses, la razón de tasas de incidencia de MACE entre los grupos de alta temprana y no temprana fue de 0,77 (IC 95 % 0,25-2,58; p = 0,61). Las variables asociadas de forma independiente con MACE fueron la revascularización completa (HR 0,18; IC 95% 0,03-0,95) y el tiempo de fluoroscopía (HR 1,02; IC 95% 1,01-1,05). No hubo diferencias significativas en las complicaciones del acceso vascular, las tasas de reingreso a 30 días y sobrevida global entre los grupos. Conclusiones: El alta temprana en pacientes con IAMCEST de bajo riesgo tratados con ATCp puede ser factible incluso en países en desarrollo, sin aumento significativo de la morbimortalidad.

ABSTRACT Background and objectives: Early discharge (within the first 48 hours) in patients with ST-segment elevation myocardial infarction (STEMI) managed with primary percutaneous coronary intervention (PCI) with stenting is a strategy that has been adopted in developed countries. However, its implementation in South America has been uneven. Methods: We conducted an uncontrolled intervention pilot study on low-risk STEMI patients managed with primary PCI to evaluate the early discharge rate and compare the incidence of major adverse cardiovascular events (MACE) with those occurring in patients discharged later. Results: Of 320 STEMI patients managed with primary PCI from 2013 to 2021, 158 were low-risk patients and 63.9% (95% CI 55.9-71,4%) of them were discharged early. Diabetes (OR 0.31, 95% CI 0.12-0.83), and anterior wall STEMI (OR 0.34, 95% CI 0.16-0.69) were independently associated with lower probability of early discharge. During a median follow-up period of 27.2 months, the incidence rate ratio of MACE between the early discharge and non-early discharge groups was 0.77 (95% CI 0.25-2.58; p = 0.61). The variables independently associated with MACE were complete revascularization (HR 0.18, 95% CI 0.03-0.95) and fluoroscopy time (HR 1.02, 95% CI 1.01-1.05). There were no significant differences in vascular access complications, 30-day readmission rate and overall survival between groups. Conclusions: Early discharge in low-risk STEMI patients managed with primary PCI may be feasible even in developing countries, without significantly increasing morbidity and mortality.

Predictors of Bleeding after Percutaneous Coronary Intervention

Background: Acute coronary syndrome patient outcomes have been improved using early invasive techniques. The aim of this study was to investigate the incidence, location, and severity of bleeding in PCI-treated cases to identify patient risk profiles and increased bleeding occurrences. Methods: This prospective observational study evaluated percutaneous coronary angiography in 80 patients with hypertension and diabetes mellitus who planned to undergo primary or elective PCI. The cases were separated into 2 groups; those who reported bleeding (n=11) and those who did not (n=69). All patients underwent physical examination, laboratory evaluation, 12-lead electrocardiography, and PCI. Results: In univariate regression analysis, age (OR: 1.09, 95% CI: 1.009 – 1.192), female gender (OR: 4.32, 95% CI: 1.157 – 16.131), history of peripheral arterial disease (OR: 7.31, 95% CI: 1.585 – 33.742), and femoral site of vascular access (OR: 9.6, 95% CI: 2.263 – 40.721) were independent predictors of major bleeding after PCI. In multivariate regression analysis, age (OR: 1.12, 95% CI:1.014 – 1.269), female gender (OR: 13.75, 95% CI: 1.983 – 161.2), history of peripheral arterial disease (OR: 43.38, 95% CI: 3.754 - 1042) and femoral site of vascular access (OR: 13.29, 95% CI: 2.233 – 128.5) were independent predictors of major bleeding after PCI. Conclusions: Patients who reported bleeding after PCI had a significantly higher age, prevalence of female sex, serum creatinine, and transfemoral intervention before and after intervention compared to patients who did not report bleeding, while haemoglobin and transradial intervention before and after intervention were significantly lower in the bleeding cases than in the non-bleeding cases.

The Relationship between CHA2DS2-VASc Score and Reperfusion Success in Elective Percutaneous Saphenous Vein Graft Interventions

Abstract Background Patients with degenerated saphenous vein grafts (SVG) have a higher risk of developing no-reflow. The CHA2DS2-VASc score was established as a no-reflow predictor in patients with acute coronary syndrome (ACS). Objectives In our study, we aimed to assess the association between CHA2DS2-VASc score and no-reflow after the procedure and short-term mortality in patients with SVG who underwent elective percutaneous coronary intervention (PCI). Methods Our retrospective study comprised 118 patients who were divided into two groups according to the occurrence of the no-reflow phenomenon. The groups were compared on the basis of demographic characteristics, angiographic parameters, CHA2DS2-VASc scores, and outcome. A logistic regression analysis was additionally performed to determine the predictors of no-reflow. A p value of < 0.05 was considered statistically significant. Results Mean age of the participants was 66.4 ± 9.2 years, and 25.4% of them were female. Apart from the history of diabetes (p = 0.032), demographic data, blood parameters, ejection fraction, total stent length and diameter, medication use, median CHA2DS2-VASc score, and adverse cardiac events did not differ between the groups. In univariate logistic regression analysis, the presence of diabetes and stent length appeared to be associated with no-reflow, but not in multivariate analysis. The median CHA2DS2-VASc score was higher in non-survivors at 1-year follow-up (4.5 versus 3, p = 0.047). Conclusions In our study, we did not observe a significant relationship between no-reflow and CHA2DS2-VASc score. Larger studies are needed to reveal the indicators of improved post-intervention reperfusion in elective SVG PCI.

Management of Bifurcation Culprit Lesion in the Setting of Anterior ST Elevation Myocardial Infarction

Introduction: Coronary bifurcation lesions are considered one of the challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. However, there is limited data about the proper management of such lesions in the setting of myocardial infarction as most bifurcation lesion studies excluded patients with acute coronary syndromes (ACS). The aim of this study was to compare in-hospital and mid-term outcomes of single-stent and two-stents strategy in the management of bifurcation culprit lesions in patients presenting with anterior STEMI. Methods: This retrospective multi-center study included all patients presented with anterior STEMI who underwent primary PCI between January 2017 and December 2019, coronary angiography showed true bifurcation lesion with sizable side branch that can be managed by stenting. Patients with left main bifurcation, those indicated for urgent CABG, and patients in cardiogenic shock were excluded. Included patients were divided into two groups according to the stenting strategy either single or two stents. Six months follow up data were collected by telephone calls and by examination of medical records. Results: Out of 1355 anterior STEMI patients presented between January 2017 and December 2019, 158 patients (11.6%) were identified to have bifurcation culprit lesions with a sizable diagonal branch. 93 patients (59%) were treated by single stent while 65 patients (41%) were managed by two-stents strategy. The baseline characteristics and angiographic findings were similar in both groups except for higher side branch involvement in the two stents group (83.31%±11.20 vs 71.88%±15.05, t= -5.39, p <0.001). Mean fluoroscopy time (23.96±8.90 vs 17.81±5.72 mins) and contrast volume (259.23± 59.45 vs 232.58± 96.18 ml) were significantly higher in two stents group than single stent group (p=0.049). However, the angiographic success rates (residual stenosis ?30% and restoration of TIMI flow grade II or III) were comparable (96.8% vs 99%, MCp=0.151). There is no significant difference in the overall incidence rate of MACE in both groups 6 months following the index procedure (13.9 % vs 16.9%, FEp=0.698), with no difference between different bifurcation stenting techniques in patients managed with two stents. Conclusion: Although two stents strategy in the setting of STEMI is much complex with more fluoroscopy time and contrast volume, the procedural success rate and the incidence of MACE were comparable to one stent strategy, on medium-term follow up.

No reflow phenomenon in CAD patients after percutaneous coronary intervention: A prospective hospital based observational study

The present study assessed incidence, risk factors, in-hospital and short-term outcomes associated with no-reflow in patients undergoing percutaneous coronary intervention (PCI) in STEMI, NSTEMI, unstable angina and stable angina. Out of 449 patients, 42 (9.3%) developed no-reflow. Hypertension, dyslipidemia, obesity and smoking were significant risk factors. There was significant association of no-reflow with left main disease, multiple stents, target lesion length_x0001_ 20 mm and higher thrombus grade. Interestingly, 93 patients (23.4%) of normal flow had myocardial perfusion grade (MPG) of 0/1 with mortality in 9 (10%) patients. No-reflow is associated with poor in-hospital and short-term outcomes with higher incidence of death, cardiogenic shock, heart failure and MACE. Knowledge of risk factors of no-reflow portends a more meticulous approach to improve final outcomes. MPG could be better predictor of outcomes in these patients.

Complete revascularization with PCI in STEMI patients with multivessel disease, when is the appropriate time? / Revascularización completa mediante ICP en pacientes con STEMI y enfermedad coronaria multivaso, ¿cuál es el momento adecuado?

Abstract Objective: The purpose was to compare the outcomes of patients with ST-elevation myocardial infarction and multivessel coronary artery disease undergoing one-time multivessel revascularization (OTMVR) versus in-hospital staged complete revascularization with percutaneous coronary intervention. Methods: This was a single-center, retrospective, observational, and cohort study, including data from January 2013 to April 2019. A total of 634 patients were included in the study. Comparisons were made between patients who underwent in-hospital staged complete revascularization versus OTMVR. The primary endpoint was all-cause in-hospital mortality, secondary endpoints included cardiovascular complications, all-cause new hospitalization, and mortality evaluated at 30 days and 1 year. In addition, we constructed a logistic regression model for determining the risk factors that predicted mortality. Results: Of the 634 patients, 328 were treated with staged revascularization and 306 with OTMVR. About 76.7% were men, with a mean age of 63.3 years. Less complex coronary lesions and a higher proportion of the left anterior descending artery as the culprit vessel were found in the OTMVR group. Compared with staged revascularization, the primary and secondary endpoints occurred less frequently with OTMVR strategy. Conclusions: OTMVR did not generate more complications and demonstrate better clinical outcomes than in-hospital staged revascularization.

Resumen Objetivo: El propósito fue comparar resultados de pacientes con infarto agudo de miocardio con elevación del segmento ST y enfermedad coronaria multivaso sometidos a revascularización completa de un solo momento frente a revascularización completa por etapas mediante intervención coronaria percutánea. Métodos: Estudio cohorte observacional, retrospectivo, unicéntrico, con datos de enero de 2013 a abril de 2019, incluyendo 634 pacientes. Se compararon resultados entre pacientes sometidos a revascularización completa por etapas frente a revascularización completa en un solo momento. El objetivo primario fue valorar mortalidad intrahospitalaria por cualquier causa y como objetivos secundarios se evaluaron a 30 días y 1 año las complicaciones cardiovasculares, hospitalizaciones y mortalidad. Se construyó un modelo de regresión logística para determinar los factores de riesgo que predijeron mortalidad. Resultados: De 634 pacientes, 328 fueron tratados con revascularización por etapas y 306 con revascularización en una intervención. El 76.7% fueron hombres, con una media de edad de 63.3 años. En el grupo de revascularización de un solo tiempo se encontraron lesiones coronarias menos complejas y una mayor proporción de la arteria descendente anterior como vaso culpable. Comparado con el grupo de revascularización por etapas, los objetivos primarios y secundarios ocurrieron con menos frecuencia en el grupo de revascularización en un solo tiempo. Conclusiones: Comparada con la revascularización intrahospitalaria por etapas, la revascularización en una intervención lleva a mejores desenlaces clínicos sin generar más complicaciones.

Selvester score and myocardial performance index in acute anterior myocardial infarction

SUMMARY BACKGROUND: The simplified Selvester QRS score is a parameter for estimating myocardial damage in ST-elevation myocardial infarction. ST-elevation myocardial infarction leads to varying degrees of impairment in left ventricular systolic and diastolic function. Myocardial performance index is a single parameter that can predict combined left ventricular systolic and diastolic performance. OBJECTIVE: We investigated the relationship between Selvester score and myocardial performance index in patients undergoing primary percutaneous coronary intervention for acute anterior myocardial infarction. METHODS: The study included 58 patients who underwent primary percutaneous coronary intervention for acute anterior myocardial infarction. Selvester score of all patients was also calculated at 72 h. Patients were categorized into two groups according to the Selvester score. Those with a score <6 (low score) were considered group 1 and those with a score ≥6 (high score) were considered group 2. RESULTS: When compared with group 1, patients in group 2 were older (p=0.01) and had lower left ventricular ejection fractions (50.3±4 vs. 35.6±6.9, p=0.001), and conventional myocardial performance index (0.52±0.06 vs. 0.69±0.08, p=0.001), lateral tissue Doppler-derived myocardial performance index (0.57±0.08 vs. 0.72±0.08, p=0.001), and septal tissue Doppler-derived myocardial performance index (0.62±0.07 vs. 0.76±0.08, p=0.001) were higher. There was a high correlation between lateral tissue Doppler-derived myocardial performance index and conventional myocardial performance index and Selvester score (r=0.80, p<0.001; r=0.86, p<0.001, respectively) and a moderate correlation between septal tissue Doppler-derived myocardial performance index and Selvester score (r=0.67, p<0.001). CONCLUSIONS: The post-procedural Selvester score can predict lateral tissue Doppler-derived myocardial performance index and conventional myocardial performance index with high sensitivity and acceptable specificity in patients undergoing primary percutaneous coronary intervention for acute anterior myocardial infarction.

Multi-vessel Disease Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in Patients with Chronic Kidney Disease

Background: Revascularization of the coronary arteries is associated with better short term and long term prognosis in patients having multivessel coronary artery disease (MV-CAD) and chronic kidney disease (CKD). However, whether revascularization using coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI) using drug eluting stents (DES) is better remains unknown. Objectives: To compare the outcomes of revascularization by multi-vessel PCI using DES versus revascularization by CABG in patients with CKD having multivessel CAD, regarding in-hospital and one-year major adverse cardiovascular and cerebrovascular events (MACCE). Methods: This was a retrospective analysis of the data of a group of patients having CKD with eGFR less than 60 ml/min with multivessel CAD who underwent revascularization by PCI or revascularization by CABG and were compared as regards in-hospital and one-year MAACE. Results: A total of 565 patients were reviewed in this study, 230 patients had multivessel PCI using DES while 335 patients had CABG. Comparing both revascularization groups regarding in-hospital MACCE, patients who had mutli-vessel PCI had significantly lower in-hospital mortality, cerebrovascular events (stroke/TIA) and lower total MACCE than patients who had CABG (P-value = 0.03 & 0.01 & 0.04 respectively). When comparing both revascularization groups regarding one-year MACCE, patients who had mutli-vessel PCI had significantly lower cerebrovascular events and total MACCE than those patients who had CABG (P-value = 0.02 & 0.03 respectively). Conclusion: This is a retrospective study to determine which strategy is better for revascularization of CKD patients having multivessel CAD; we can conclude that multi-vessel PCI using DES for CKD patients and multivessel CAD had advantages over CABG regarding in-hospital and one-year cerebrovascular accidents (TIA/stroke) and regarding total MACCE. Larger randomized controlled trials are required to confirm our findings.

Experiência inicial com a extensão de cateter-guia ExpressmanTM em um centro terciário de cardiologia de alto volume / Initial experience with the ExpressmanTM guide catheter extension in a high-volume tertiary cardiology center

Introdução: As extensões de cateter-guia fornecem maior suporte em intervenções coronárias percutâneas complexas. O ExpressmanTM é uma nova extensão de cateter-guia, e nosso objetivo foi avaliar o impacto de seu uso no sucesso do procedimento e nas complicações ocorridas em um centro de referência de alto volume. Métodos: Analisamos os dados de todos os procedimentos consecutivos em que foi usada uma extensão de cateter-guia ExpressmanTM. A decisão de usar uma extensão de cateter-guia ficou a critério do operador. O sucesso do dispositivo foi definido como o posicionamento bem-sucedido da extensão de cateter-guia dentro do vaso coronário, e o sucesso do procedimento foi definido como <20% de estenose residual e fluxo TIMI 3, sem perda significativa de ramos laterais. Eventos adversos cardíacos e cerebrovasculares maiores foram definidos como a combinação morte por todas as causas, infarto do miocárdio, revascularização do vaso-alvo e acidente vascular cerebral. Resultados: Foram incluídos 34 procedimentos entre abril de 2022 e janeiro de 2023. A maioria dos pacientes era do sexo masculino (59%), e a média de idade foi 66,5 anos. O uso da extensão de cateter-guia não foi planejado antes do procedimento em 17 procedimentos (50%). Os motivos mais comuns para o uso da extensão de cateter-guia foram angulação ou tortuosidade do vaso-alvo e posição desfavorável do óstio coronário. O sucesso do dispositivo foi obtido em 88% e o da revascularização, em 91%. Houve três oclusões de ramo lateral. Durante o acompanhamento clínico intra-hospitalar, não ocorreram sangramento e nem eventos adversos cardíacos e cerebrovasculares maiores. Conclusão: O sucesso do dispositivo e do procedimento foi alto, e a taxa de complicações foi baixa. O uso da extensão de cateter-guia como técnica de resgate em anatomias complexas permitiu o sucesso do procedimento na maioria dos pacientes que, de outro modo, não poderiam ser tratados.

Background: Guide catheter extensions provide increased support in complex percutaneous coronary interventions. The ExpressmanTM is a novel guide catheter extension and the objective was to assess the impact of its use on procedural success and complications in a high-volume reference center. Methods: We analyzed data from all consecutive procedures in which the ExpressmanTM guide catheter extension was used. The decision to use a guide catheter extension was at operator's discretion. Device success was defined as the successful positioning of the guide catheter extension in the coronary vessel and procedural success was defined as <20% residual stenosis and TIMI 3 flow, with no loss of significant side branches. Major adverse cardiac and cerebrovascular events were defined as the composite of all-cause death, myocardial infarction, target vessel revascularization and stroke. Results: From April 2022 to January 2023, 34 procedures were included. The majority of the patients were male (59%) and the mean age was 66.5 years. Guide catheter extension use was not planned pre-procedure in 17 procedures (50%). The most common reasons for guide catheter extension use were target vessel angulation or tortuosity and unfavorable coronary ostium position. Device success was obtained in 88% and revascularization success in 91%. There were three side branch occlusions. During in-hospital clinical follow-up, no major adverse cardiac and cerebrovascular events or major bleeding occurred. Conclusion: The device success and procedural success were high and the rate of complications was low. Guide catheter extension use as bailout technique in complex anatomies allowed procedural success in the vast majority of otherwise untreatable patients.

Relação entre a Relação Fibrinogênio/Albumina e a Perfusão Microvascular em Pacientes Submetidos à Intervenção Coronária Percutânea Primária para Infarto do Miocárdio com Elevação do Segmento ST: Um Estudo Prospectivo / Relationship between the Fibrinogen/Albumin Ratio and Microvascular Perfusion in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevated Myocardial Infarction: A Prospective Study

Resumo Fundamento A contagem corrigida de quadros TIMI (CTFC), o grau de blush miocárdico (MBG) e a resolução do segmento ST (STR) são parâmetros utilizados para avaliar a reperfusão em nível microvascular em pacientes submetidos à intervenção coronária percutânea primária (ICPp). A relação fibrinogênio/albumina (FAR) tem sido associada a eventos trombóticos em pacientes com infarto do miocárdio com elevação do segmento ST (IAMCSST) e insuficiência venosa crônica. Objetivos Investigar a relação do FAR com CTFC, MBG e STR.Métodos: O estudo incluiu 167 pacientes consecutivos que foram submetidos a ICPp com sucesso para IAMCSST e alcançaram fluxo TIMI-3. Os casos foram divididos em dois grupos, FAR alto (> 0,0765) e FAR baixo (≤ 0,0765), de acordo com o valor de corte desse parâmetro na análise característica do operador do receptor (ROC). STR, CTFC e MBG foram utilizados para avaliar a reperfusão miocárdica. Valores de p<0,05 foram considerados estatisticamente significativos. Resultados O valor CTFC, escore SYNTAX, relação neutrófilos/linfócitos, lipoproteína de baixa densidade, glicose e pico de cTnT foram significativamente maiores, enquanto STR, MBG e FEVE foram menores no grupo FAR alto. A análise de correlação de Spearman revelou relação significativa entre FAR e STR (r=-0,666, p<0,001), MBG (-0,523, p<0,001) e CTFC (r=0,731, p≤0,001). De acordo com a análise de regressão logística, FAR, glicose, pico de cTnT e dor até o tempo de Balão foram os preditores independentes mais importantes de MBG 0/1, CTFC>28 e STR<50%). A análise ROC revelou que o ponto de corte o valor de FAR≥0,0765 foi preditor de STR incompleto com sensibilidade de 71,9% e especificidade de 69,8%, MBG0/1 com sensibilidade de 72,6% e especificidade de 68,6%, e CTFC>28 com sensibilidade de 76% e uma especificidade de 65,8%. Conclusões A FAR é um importante preditor independente de perfusão microvascular em pacientes submetidos a ICPp por IAMCSST.

Abstract Background Correct TIMI frame count (CTFC), myocardial blush grade (MBG), and ST-segment resolution (STR) are parameters used to evaluate reperfusion at the microvascular level in patients that have undergone primary percutaneous coronary intervention (pPCI). Fibrinogen-to-albumin ratio (FAR) has been associated with thrombotic events in patients with ST-elevation myocardial infarction (STEMI) and chronic venous insufficiency. Objectives To investigate the relationship of FAR with CTFC, MBG, and STR. Methods: The study included 167 consecutive patients who underwent successful pPCI for STEMI and achieved TIMI-3 flow. The cases were divided into two groups, high (>0.0765) and low FAR (≤0.0765), according to the cut-off value of this parameter in the receiver operator characteristic analysis (ROC). STR, CTFC, and MBG were used to evaluate myocardial reperfusion. P values<0.05 were considered statistically significant. Results CTFC value, SYNTAX score, neutrophil/lymphocyte ratio, low-density lipoprotein, glucose, and peak cTnT were significantly higher, whereas STR, MBG, and LVEF were lower in the high FAR group. Spearman's correlation analysis revealed a significant relationship between the FAR and STR (r=-0.666, p<0.001), MBG (-0.523, p<0.001), and CTFC (r=0.731, p≤0.001). According to the logistic regression analysis, FAR, glucose, peak cTnT, and pain to balloon time were the most important independent predictors of MBG 0/1, CTFC>28, and STR<50%).ROC analysis revealed that the cut-off value of FAR≥0.0765 was a predictor of incomplete STR with a sensitivity of 71.9 % and a specificity of 69.8 %, MBG0/1 with a sensitivity of 72.6 % and a specificity of 68.6 %, and CTFC >28 with a sensitivity of 76 % and a specificity of 65.8 %. Conclusions FAR is an important independent predictor of microvascular perfusion in patients undergoing pPCI for STEMI.

Bivalirudin vs heparin in cardiac-cerebral ischemic and bleeding events among Chinese STEMI patients during percutaneous coronary intervention: a retrospective cohort study

Although bivalirudin has been recently made available for purchase in China, large-scale analyses on the safety profile of bivalirudin among Chinese patients is lacking. Thus, this study aimed to compare the safety profile of bivalirudin and heparin as anticoagulants in Chinese ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). A total of 1063 STEMI patients undergoing PCI and receiving bivalirudin (n=424, bivalirudin group) or heparin (n=639, heparin group) as anticoagulants were retrospectively enrolled. The net adverse clinical events (NACEs) within 30 days after PCI were recorded, including major adverse cardiac and cerebral events (MACCEs) and bleeding events (bleeding academic research consortium (BARC) grades 2-5 (BARC 2-5)). The incidences of NACEs (10.1 vs 15.6%) (P=0.010), BARC 2-5 bleeding events (5.2 vs 10.3%) (P=0.003), and BARC grades 3-5 (BARC 3-5) bleeding events (2.1 vs 5.5%) (P=0.007) were lower in the bivalirudin group compared to the heparin group, whereas general MACCEs incidence (8.9 vs 6.4%) (P=0.131) and each category of MACCEs (all P>0.05) did not differ between two groups. Furthermore, the multivariate logistic analyses showed that bivalirudin (vs heparin) was independently correlated with lower risk of NACEs (OR=0.508, P=0.002), BARC 2-5 bleeding events (OR=0.403, P=0.001), and BARC 3-5 bleeding events (OR=0.452, P=0.042); other independent risk factors for NACEs, MACCEs, or BARC bleeding events included history of diabetes mellitus, emergency operation, multiple lesional vessels, stent length >33.0 mm, and higher CRUSADE score (all P<0.05). Thus, bivalirudin presented a better safety profile than heparin among Chinese STEMI patients undergoing PCI.

Clinical value of combined plasma brain natriuretic peptide and serum cystatin C measurement on the prediction of heart failure in patients after acute myocardial infarction

This research investigated the predictive value of combined detection of brain natriuretic peptide (BNP) and cystatin C (Cys C) in heart failure after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Sixty-five AMI patients complicated by heart failure (HF) after PCI and 79 non-heart failure (non-HF) patients were involved in this research. The levels of Cys C and BNP were measured. Risk factors for heart failure in AMI patients after PCI were analyzed by multivariate logistic regression analysis. Efficacy of BNP and Cys C on predicting heart failure were analyzed by receiver operating characteristic (ROC) curve. Cys C and BNP levels were significantly higher in the HF group than in the non-HF group. BNP and Cys C levels were the independent influencing factors causing heart failure within one year after PCI. The area under the predicted curve (AUC) of Cys C, BNP, and combined Cys C and BNP were 0.763, 0.829, and 0.893, respectively. The combined detection of Cys C and BNP was highly valuable in predicting heart failure in AMI patients after PCI, which can be regarded as the serum markers for diagnosis and treatment of heart failure.