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.

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.

Predictive values of bilirubin for in-hospital adverse events in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

Abstract Purpose To investigate the association between serum bilirubin levels and in-hospital Major Adverse Cardiac Events (MACE) in patients with ST-segment Elevation Myocardial Infarction (STEMI) undergoing primary Percutaneous Coronary Intervention (PCI). Methods A total of 418 patients with STEMI who underwent primary PCI were enrolled from October 1st, 2021 to October 31st 2022. The average age of enrolled participants was 59.23 years, and 328 patients (78.50%) were male patients. Patients were divided into MACE (patients with angina pectoris after infarction, recurrent myocardial infarction, acute heart failure, cardiogenic shock, malignant arrhythmias, or death after primary PCI) (n = 98) and non-MACE (n = 320) groups. Univariate and multivariate logistic regression analyses were performed to estimate the association between different bilirubin levels including Total Bilirubin (TB), Direct Bilirubin (DB), Indirect Bilirubin (IDB), and risk of in-hospital MACE. The area under the Receiver Operating Characteristic (ROC) curve was used to determine the accuracy of bilirubin levels in predicting in-hospital MACE. Results The incidence of MACE in STEMI patients increased from the lowest to the highest bilirubin tertiles. Multivariate logistic regression analysis showed that increased total bilirubin level was an independent predictor of in-hospital MACE in patients with STEMI (p for trend = 0.02). Compared to the first TB group, the ORs for risk of MACE were 1.58 (95% CI 0.77‒3.26) and 2.28 (95% CI 1.13‒4.59) in the second and third TB groups, respectively. The ROC curve analysis showed that the areas under the curve for TB, DB and IDB in predicting in-hospital MACE were 0.642 (95% CI 0.578‒0.705, p < 0.001), 0.676 (95% CI 0.614‒0.738, p < 0.001), and 0.619 (95% CI 0.554‒0.683, p < 0.001), respectively. Conclusions The current study showed that elevated TB, DB, and IDB levels are independent predictors of in-hospital MACE in patients with STEMI after primary PCI, and that DB has a better predictive value than TB and IDB.

Short-term outcomes among patients with subclinical hypothyroidism undergoing primary percutaneous coronary intervention

Objectives: This study aimed to examine possible associations between previously undiagnosed subclinical hypothyroidism and short-term outcomes and mortality in a sample of Iraqi patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Design: This is a prospective observational cohort study. Setting: The study was conducted in a single tertiary referral centre in Baghdad, Iraq. Participants: Thyroid-stimulating hormone and free T4 levels were measured in 257 patients hospitalised with STelevation myocardial infarction who underwent primary percutaneous coronary intervention between January 2020 and March 2022. Main outcome measures: Adverse cardiovascular and renal events during hospitalisation and 30-day mortality were observed. Results: Previously undiagnosed subclinical hypothyroidism was detected in 36/257 (14%) ST-elevation myocardial infarction patients and observed more commonly in females than males. Patients with subclinical hypothyroidism had significantly worse short-term outcomes, including higher rates of suboptimal TIMI Flow (< III) (p =0.014), left ventricular ejection fraction ≤ 40% (p=0.035), Killip class >I (p=0.042), cardiogenic shock (p =0.016), cardiac arrest in the hospital (p= 0.01), and acute kidney injury (p= 0.044). Additionally, 30-day mortality was significantly higher in patients with subclinical hypothyroidism (p= 0.029). Conclusion: Subclinical hypothyroidism previously undiagnosed and untreated had a significant association with adverse short-term outcomes and higher short-term mortality within 30 days compared to euthyroid patients undergoing primary percutaneous coronary intervention. Routine thyroid function testing during these patients' hospitalisation may be warranted.

Construction of visual prediction model for no reflow phenomenon in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention / 中华急诊医学杂志

Objective:To build a simple, rapid and accurate visual prediction model for identifying the ST-segment elevation myocardial infarction (STEMI) patients with high risk of no reflow during the primary percutaneous coronary intervention (PPCI).Methods:A retrospective study of STEMI patients treated by PPCI in China-Japan Friendship Hospital from January 2018 to June 2019 was performed. The clinical data including sex, age, comorbidities, personal history, Killip classification and laboratory examinations were collected. Whether the patients had no reflow during the PPCI were retrospective observed. Multivariable logistic regression analysis was used to identify risk factors. A nomogram was developed to predict no reflow risk among STEMI patients. C-index and Hosmer-Lemeshow goodness-of-fit test were used to verify the differentiation, consistency and clinical applicability of the model. Internal verification of the model was used by Bootstrap validation.Results:Of the included 280 patients, the prevalence of no flow rate was 30.7%. Killip class Ⅲ or Ⅳ ( OR=3.537, 95% CI: 1.665-7.514, P=0.002), mean platelet volume≥9 fL ( OR=4.003, 95% CI: 1.091-14.689, P=0.037), Glucose ≥7.8 mmol/L ( OR=2.315, 95% CI: 1.318-4.066, P=0.003) and time from symptoms to hospital ( OR=5.594, 95% CI: 2.041-15.328, P=0.002) were the independent risk factors of no flow (all P<0.05). The AUC of ROC curve in the prediction model was 0.731 (95% CI: 0.668-0.795). The calibration curves were close to the standard curve. Conclusions:The visual prediction model constructed in this study can early identify STEMI patients with high risk of no reflow, and may be helpful for physicians to provide prospective pre-treatment before the occurrence of no reflow during PPCI.

Early reperfusion strategy selection and prognosis analysis in patients with acute ST segment elevation myocardial infarction: based on the data of 49 hospitals in Hebei Province / 中华危重病急救医学

Objective:To explore the selection of strategies for early reperfusion therapy and its impact on prognosis in patients with acute ST segment elevation myocardial infarction (STEMI).Methods:The treatment data and 3-year follow-up results of acute myocardial infarction (AMI) patients in 49 hospitals in Hebei Province from January to December 2016 were collected. Patients with STEMI who received either intravenous thrombolytic therapy (ITT) or primary percutaneous coronary intervention (PPCI) within 12 hours of onset were enrolled. Baseline data, the time from the first diagnosis to the start of reperfusion (FMC2N for ITT patients and FMC2B for PPCI patients), vascular recanalization rate, in-hospital mortality, 1-year mortality, and 3-year mortality were compared between ITT and PPCI groups. The efficacy and prognosis of ITT and PPCI at different starting time of reperfusion (FMC2N≤30 minutes, FMC2N > 30 minutes, FMC2B≤120 minutes, FMC2B > 120 minutes) were analyzed.Results:A total of 1 371 STEMI patients treated with ITT or PPCI were selected, including 300 patients in the ITT group and 1 071 patients in the PPCI group. 1 055 patients were actually followed up (205 patients in the ITT group and 850 patients in the PPCI group), with a rate of 79.4%. There were no significant differences in age, gender, and previous history between the two groups. The time from the first diagnosis to the start of reperfusion in the ITT group was shorter than that in the PPCI group [minutes: 63 (38, 95) vs. 95 (60, 150), U = -9.286, P = 0.000], but was significantly longer than the guideline standard. Compared with the ITT group, the vascular recanalization rate in the PPCI group was higher [95.5% (1 023/1 071) vs. 88.3% (265/300), P < 0.01], and in-hospital mortality was lower [2.1% (22/1 071) vs. 6.7% (20/300), P < 0.01], but there were no significant differences in the 1-year mortality and 3-year mortality [5.3% (45/850) vs. 4.4% (9/205), 9.5% (81/850) vs. 9.3% (19/205), both P > 0.05]. Between ITT group and PPCI group with different reperfusion starting time, the FMC2N > 30 minutes group had the lowest vascular recanalization rate and the highest in-hospital mortality. Pairwise comparison showed that the vascular recanalization rate of the FMC2B ≤ 120 minutes group and the FMC2B > 120 minutes group were significantly higher than those of the FMC2N > 30 minutes group [95.5% (654/685), 95.6% (369/386) vs. 88.0% (220/250), both P < 0.008], the in-hospital mortality was significantly lower than that of the FMC2N > 30 minutes group [2.0% (14/685), 2.1% (8/386) vs. 7.6% (19/250), both P < 0.008]. There was no significant difference in 1-year mortality (χ 2 = 2.507, P = 0.443) and 3-year mortality (χ 2 = 2.204, P = 0.522) among the four groups. Conclusions:For STEMI patients within 12 hours of onset, reperfusion therapy should be performed as soon as possible. PPCI showed higher infarct related artery opening rate and lower in-hospital mortality compared with ITT, and had no effect on 1-year and 3-year mortality.

Effect of ischemic postconditioning during primary percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction: A single-center cross-sectional study

Background and Objective: Reperfusion therapy for acute myocardial infarction has been shown to reduce mortality, yet it may also have deleterious effects, including myocardial necrosis and no-reflow. Postconditioning is known measure for cardioprotection from reperfusion injury in animal model. Postconditioning is known measure for cardioprotection from reperfusion injury in animal model and human studies have shown inconsistent results. Materials and Methods: From February 2013 through October 2014, at Institute of Postgraduate Medical Education and Research, Kolkata Cardiology department, we randomized 43 patients with acute ST-segment elevation myocardial infarction (STEMI) who were undergoing conventional primary percutaneous coronary intervention (PCI) (22 patients) and PCI with postconditioning by repeated transient balloon occlusion after establishment of flow (21 patients). Total creatine kinase-muscle/brain (CPK-MB) released within 72 h was compared as a surrogate marker of infarct size. Myocardial blush grade between two groups was also compared. Results: The area under curve of serum creatine kinase (CK) release during the 1st 72 h of reperfusion was significantly reduced (P = 0.0347) in the postconditioned group compared with the control group, averaging 9632 IU in postconditioned compared with 13493 IU in control group which represented 29% of reduction of infarct size. The peak of CPK-MB release was markedly lower in the postconditioned (290 ± 16.24 IU/L) than in the control (414.2 ± 51.34 IU/L) group (P ≤ 0.0001). Blush grading was also significantly improved in postconditioned group (P = 0.005). Mean ST-segment deviation at 48 h between cases and control groups was 0.87 ± 0.68 and 1.4 ± 0.94, respectively (P = 0.08). Conclusion: In patients with STEMI, postconditioning significantly improves blush grading and enzymatic infarct size reduction with a trend toward significant reduction of mean ST-segment deviation.

A qualitative study on the construction of clinical problems based on the guidelines of primary percutaneous coronary intervention nursing practice / 中国实用护理杂志

Objective@#To understand the working categories of primary percutaneous coronary intervention (PCI) nursing and its existing problems, and to provide a realistic basis for the construction of primary PCI in clinical nursing.@*Methods@#Qualitative interviews were used to carry out semi-structured and personal in-depth interviews among 5 doctors and 27 nurses in 5 hospitals. 7 step analysis of Colaizzi was used to analyze the data.@*Results@#The working categories of primary PCI nursing involves professional team management, early identification, preoperative preparation, evaluation and predictive nursing, disease observation, safe transfer, psychological nursing and health guidance.@*Conclusion@#Primary PCI nursing is still in the stage of continuous optimization, but some parts of the process are not standardized and the nursing behavior is inconsistent. Primary PCI nursing needs to form nursing behavior norms under the guidelines of evidence-based medicine.

A risk score model for predicting cardiac rupture after acute myocardial infarction / 中华医学杂志(英文版)

Background:@#Cardiac rupture (CR) is a major lethal complication of acute myocardial infarction (AMI). However, no valid risk score model was found to predict CR after AMI in previous researches. This study aimed to establish a simple model to assess risk of CR after AMI, which could be easily used in a clinical environment.@*Methods:@#This was a retrospective case-control study that included 53 consecutive patients with CR after AMI during a period from January 1, 2010 to December 31, 2017. The controls included 524 patients who were selected randomly from 7932 AMI patients without CR at a 1:10 ratio. Risk factors for CR were identified using univariate analysis and multivariate logistic regression. Risk score model was developed based on multiple regression coefficients. Performance of risk model was evaluated using receiveroperating characteristic (ROC) curves and internal validity was explored using bootstrap analysis.@*Results:@#Among all 7985 AMI patients, 53 (0.67%) had CR (free wall rupture, n=39; ventricular septal rupture, n=14). Hospital mortalities were 92.5% and 4.01% in patients with and without CR (P < 0.001). Independent variables associated with CR included: older age, female gender, higher heart rate at admission, body mass index (BMI) <25 kg/m2, lower left ventricular ejection fraction (LVEF) and no primary percutaneous coronary intervention (pPCI) treatment. In ROC analysis, our CR risk assess model demonstrated a very good discriminate power (area under the curve [AUC]= 0.895, 95% confidence interval: 0.845–0.944, optimism-corrected AUC= 0.821, P < 0.001).@*Conclusion:@#This study developed a novel risk score model to help predict CR after AMI, which had high accuracy and was very simple to use.

Risk factors for in-hospital mortality in patients with acute myocardial infarction complicated with cardiogenic shock after primary percutaneous coronary intervention / 中华急诊医学杂志

Objective To observe the risk factors of in-hospital mortality in patients with acute myocardial infarction complicated with cardiogenic shock after primary percutaneous coronary intervention (PCI).Methods Totally 111 cases of acute myocardial infarction complicated with cardiogenic shock received acute PCI from 2009 to 2015 in Beijing Anzhen Hospital were enrolled.The cases were divided into the in-hospital death group (31 cases) and the in-hospital survival group (80 cases).The general information,clinical indicators,range of myocardial infarction,coronary lesions and management,complications,drug treatment and equipment assistance of the two groups were compared,and logistic regression analysis was used to analyze the risk factors of in-hospital mortality.Results The proportions of age ≥ 75 years,hyperlipidemia,serum creatinine ＞ 110 μmol/L,LVEF ＜ 40％,anterior myocardial infarction,three-vessel lesions of coronary artery,post-PCI TIMI flow grade ＜3,acute liver injury and acute kidney injury in the in-hospital death group were significantly higher than those in the in-hospital survival group (P ＜ 0.05).The proportion of IABP used in the in-hospital death group was significantly higher than that in the in-hospital survival group (P ＜ 0.05).There were no significant differences in the distribution of culprit lesion and the treatment of stenoses in nonculprit arteries between the two groups (P ＞ 0.05).Multivariate logistic regression analysis showed that age ≥ 75 years,threevessel coronary lesions,post-PCI TIMI flow grade ＜3 and acute renal injury were independent risk factors for hospital mortality (P ＜ 0.05).Conclusions Age ≥ 75 years,three-vessel lesions of coronary artery,post-PCI TIMI flow grade ＜3 and acute kidney injury were independent risk factors of in-hospital death in patients with acute myocardial infarction complicated with cardiogenic shock after primary PCI.

A qualitative study on the construction of clinical problems based on the guidelines of primary percutaneous coronary intervention nursing practice / 中国实用护理杂志

Objective To understand the working categories of primary percutaneous coronary intervention (PCI) nursing and its existing problems, and to provide a realistic basis for the construction of primary PCI in clinical nursing. Methods Qualitative interviews were used to carry out semi-structured and personal in-depth interviews among 5 doctors and 27 nurses in 5 hospitals. 7 step analysis of Colaizzi was used to analyze the data. Results The working categories of primary PCI nursing involves professional team management, early identification, preoperative preparation, evaluation and predictive nursing, disease observation, safe transfer, psychological nursing and health guidance. Conclusion Primary PCI nursing is still in the stage of continuous optimization, but some parts of the process are not standardized and the nursing behavior is inconsistent. Primary PCI nursing needs to form nursing behavior norms under the guidelines of evidence-based medicine.

Stent diferido versus inmediato en pacientes con infarto de miocardio ST elevado y alta carga de trombo residual reclasificado en la lesión culpable / Deferred versus immediate stenting in patients with ST - segment elevation myocardial infarction and residual large thrombus burden reclassified in the culprit lesion

Resumen Introducción: Un trombo intracorononario largo reclasificado es un predictor independiente de resultados adversos y no reflujo en el infarto agudo de miocardio con elevación del ST. Pacientes con mayor carga de trombo residual tienen peor disfunción microvascular y mayor daño miocárdico. Métodos: Evaluamos retrospectivamente a 833 pacientes que fueron a angioplastia primaria entre enero del 2011 y junio del 2016. La carga de trombo residual final fue reclasificada tras realizar el cruce de la guía, predilatación con balón o tromboaspiración, para restaurar y estabilizar un flujo TIMI 2-3. Las estrategias de stent diferido vs. stent inmediato fueron comparadas, siendo el objetivo primario la incidencia de no reflujo (TIMI ≤ 2, o TIMI 3 con TMP < 2). Resultados: Cuarenta y siete pacientes (6.8%) presentaron una alta carga trombo residual reclasificado. La coronaria derecha fue la arteria culpable en 34 casos. Hubo mayor frecuencia de ectasia coronaria en el grupo de stent diferido (p = 0.005). Se encontraron menores tasas de no reflujo en el stent diferido (36% vs. 58%), con una mayor frecuencia de un TMP 3 (p = 0.005). Tras la nueva cateterización un 56% quedó libre de stent en el grupo diferido y la anticoagulación oral les fue más frecuentemente indicada (p = 0.031). La tasa de eventos cardiacos adversos mayores fue similar entre los grupos. Hubo una tendencia a una mejor función ventricular izquierda en el grupo diferido (p = 0.056). Conclusiones: El stent diferido puede ser una alternativa eficiente en pacientes con IAM CEST y alta carga de trombo residual reclasificado, después de conseguir un flujo TIMI 2-3 estable.

Abstract Background: Reclassification of a large thrombus burden is an independent predictor of major adverse cardiac events and no-reflow in patients with ST- segment elevation myocardial infarction (STEMI). Patients with a greater residual thrombus burden have worse microvascular dysfunction and greater myocardial damage. Methods: A retrospective analysis was performed on 833 STEMI patients who underwent primary percutaneous coronary intervention. The final residual thrombus burden was reclassified after the lesion was wired, and a thrombus aspiration or balloon dilatation was performed to restore and stabilise a thrombolysis in myocardial infarction (TIMI) 2-3 flow. Deferred stenting (DEI) was compared with immediate stenting (ISI) group, and the primary outcome was the incidence of no-/slow-reflow (TIMI ≤ 2, or TIMI 3 with myocardial blush grade < 2). Results: Overall, 47 patients (6.8%) had a residual large thrombus burden reclassified. The right coronary artery was the culprit vessel in 34 cases. More patients had coronary ectasia in the DSI group (P=.005). Fewer patients in the DSI had no-/slow-reflow (36% vs. 58%), and the myocardial blush grade 3 was more frequent in the DSI group (P=.005). After repeat coronary angiography in the DSI group, stenting was not performed in 56%, and oral anticoagulation was more frequent in the follow-up (P=.031). Major cardiac adverse events were similar between groups. There was a tendency to better left ventricular function in the DSI group (P=.056). Conclusions: Deferred stenting may be an efficient option in STEMI patients with a residual large thrombus burden reclassified after achieving a stable TIMI 2-3 flow.

Analysis of risk factors for non-reflow phenomenon during primary percutaneous coronary intervention in patients with first acute ST-segment-elevation myocardial infarction / 中国综合临床

Objective To investigate the risk factors of non?reflow phenomenon during primary percutaneous coronary intervention ( PPCI ) in patients with first acute ST?segment?elevation myocardial infarction ( STEMI ) . Methods Four hundred and forty?eight first acute STEMI patients who had PPCI from January 2007 to October 2010 in Beijing Anzhen Hospital were enrolled in this study. All patients were divided into two groups according to thrombolysis in myocardial infarction( TIMI) coronary flow grade during PPCI:non?reflow group(44 cases,TIMI 0?2 grade) and control group(404 cases,TIMI 3 grade). The basic clinical data, radiographic findings and operative data of the two groups were compared. The risk factors of non?reflow during PPCI operation in the first acute STEMI patients were analyzed. Results Non?reflow phenomenon occurred in 44 cases in the non?reflow group and 404 cases in the control group,the incident rate was 9. 82％(44/448) . Logistic regression analysis showed that the differences between the two groups in the completely block of culprit vessel,intraoperative bradycardia( preoperative heart rate ≥60 times / min,persistent or transient intraoperative heart rate < 60 times / min) ,age,percentage of neutrophils and other parameters were statistically significant ( P<0. 05) . Multivariate Logistic regression analysis showed that intraoperative bradycardia ( OR=3. 106,95％ CI:1. 584～6. 090) and age ( OR=1. 040,95％ CI: 1. 010～1. 070) could be used as independent risk factors for predicting non?reflow in PPCI. Conclusion Age of the patient and the occurrence of bradycardia may be independent risk factors for predicting the non reflow of PPCI in the first acute STEMI patients.

Study on the association of hypersensitivity troponin T level with coronary flow in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention / 中国生化药物杂志

Objective To study the the association of Hs-cTNT level with coronary flow in patients with ST-segment elevation myocardial infarction(STEMI) undergoing percutaneous coronary intervention(PCI).Methods130 cases with STEMI in hospital from January 2014 to December 2014 were divided into the positive group and the negative group according the level of Hs-cTNT.Multivariate analysis were used to examine the association of Hs-cTNT with coronary flow in patients with ST-Segment elevation myocardial infarction undergoing primary PCI.ResultsThe incidence of no reflow in the positive group was significantly higher than that in the negative group (P<0.05) The left ventricular ejection fraction in the positive group was significantly lower than that in the negative group (P<0.05).Multivariate analysis showed that Hs-cTNT was independently associated with coronary flow no-reflow in patients with acute STEMI post-PCI and TIMI flow fractionation events(P<0.05).ConclusionHypersensitivity troponin T is an effective marker for predicting coronary artery flow damage in patients with STEMI after PCI and evaluating risk stratification in patients with STEMI.

Differential Clinical Implications of High-Degree Atrioventricular Block Complicating ST-Segment Elevation Myocardial Infarction according to the Location of Infarction in the Era of Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: The clinical implication of high-degree (second- and third-degree) atrioventricular block (HAVB) complicating ST-segment elevation myocardial infarction (STEMI) is ripe for investigation in this era of primary percutaneous coronary intervention (PCI). We sought to address the incidence, predictors and prognosis of HAVB according to the location of infarct in STEMI patients treated with primary PCI. SUBJECTS AND METHODS: A total of 16536 STEMI patients (anterior infarction: n=9354, inferior infarction: n=7692) treated with primary PCI were enrolled from a multicenter registry. We compared in-hospital mortality between patients with HAVB and those without HAVB with anterior or inferior infarction, separately. Multivariate analyses were performed to unearth predictors of HAVB and to identify whether HAVB is independently associated with in-hospital mortality. RESULTS: STEMI patients with HAVB showed higher in-hospital mortality than those without HAVB in both anterior (hazard ratio [HR]=9.821, 95% confidence interval [CI]: 4.946-19.503, p<0.001) and inferior infarction (HR=2.819, 95% CI: 2.076-3.827, p<0.001). In multivariate analyses, HAVB was associated with increased in-hospital mortality in anterior myocardial infarction (HR=19.264, 95% CI: 5.804-63.936, p<0.001). However, HAVB in inferior infarction was not an independent predictor of increased in-hospital mortality (HR=1.014, 95% CI: 0.547-1.985, p=0.901). CONCLUSION: In this era of primary PCI, the prognostic impact of HAVB is different according to the location of infarction. Because of recent improvements in reperfusion strategy, the negative prognostic impact of HAVB in inferior STEMI is no longer prominent.

Beneficio de la implementación de un sistema de atención en red sobre las mujeres con infarto agudo de miocardio con elevación del segmento ST / Benefit of the implementation of a ST-segment elevation myocardial infarction network on women

Objetivo: El sistema de atención en red por infarto con elevación del segmento ST «Codi Infart¼ se implementó en Cataluña (España) en junio de 2009. El objetivo del estudio fue evaluar el beneficio de la instauración del Codi Infart para las mujeres atendidas en nuestra institución. Método: Las mujeres referidas para angioplastia primaria se dividieron en 2 grupos de acuerdo con el Codi Infart: grupo no-Codi Infart (enero de 2003 a mayo de 2009) y grupo Codi Infart (junio de 2009 a diciembre de 2012); y se compararon lugar de procedencia, periodos, tratamientos recibidos y tasa de eventos cardiovasculares mayores definida como muerte por todas las causas, reinfarto o accidente cerebrovascular durante el ingreso, a 30 y 180 días. Resultados: De una población total de 2,426 pacientes, 501 (20.7%) eran mujeres. De ellas, 186 mujeres (2,09 casos/mes) pertenecían al grupo no-Codi Infart y 315 mujeres (10,16 casos/mes) al grupo Codi Infart. El porcentaje de mujeres atendidas aumentó desde la introducción del Codi Infart(22.2% vs. 18.5%, p = 0.028). Además, inicialmente el grupo Codi Infart presentó mayor porcentaje de mujeres atendidas fuera de nuestra institución (84.1% vs. 16.7%, p < 0.001), y menores tiempos totales de isquemia (220 [155-380] vs. 272 [196-456], p = 0.003), pero no se detectaron diferencias en eventos cardiovasculares mayores a 180 días (14.2% vs. 15.6%, p = 0.692). Conclusiones: La instauración del Codi Infart permitió aumentar de manera notable la tasa y el porcentaje de mujeres con infarto de miocardio con elevación del segmento ST tratadas mediante angioplastia primaria y reducir los tiempos totales de isquemia.

Objective: The ST-segment elevation myocardial infarction network "Codi Infart" was implemented in Catalonia (Spain) in June 2009. The objective of this study was to evaluate the impact of the implementation of the Codi Infart on women. Method: Women referred for primary percutaneous coronary intervention, were divided into two groups according to Codi Infart: Non-Codi Infart group (January 2003 to May 2009) and Codi Infart group (June 2009 to December 2012). Place of first medical contact, time intervals in diagnosis and treatment, treatments received and rate of major cardiovascular adverse events defined as all-cause death, reinfarction or stroke in-hospital, at 30 and 180 days were compared. Results: From a total population of 2,426 patients, 501 (20.7%) were women. One-hundred eighty-six women (2.09 cases/month) belonged to Non-Codi Infart group and 315 women (10.16 cases/month) to Codi Infart group. The percentage of women attended increased since the introduction of CI (22.2% vs. 18.5%, P = .028). In addition, the Codi Infart group had a higher percentage of women initially attended outside our institution (84.1% vs. 16.7%, P < .001), and lower total ischemia time (220 [155-380] vs. 272 [196-456], P = .003). However, no differences in 180-day major cardiovascular adverse events were detected (14.2% vs. 15.6%, P = .692). Conclusions: The implementation of the major cardiovascular adverse events allowed to increase the rate and the percentage of women with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention and reducing total ischemic time.

Increased neutrophil-to-lymphocyte ratio predicts persistent coronary no-flow after wire insertion in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVES: Acute ST-segment elevation myocardial infarction patients presenting persistent no-flow after wire insertion have a lower survival rate despite successful mechanical intervention. The neutrophil-to-lymphocyte ratio has been associated with increased mortality and worse clinical outcomes in ST-segment elevation myocardial infarction. We hypothesized that an elevated neutrophil-to-lymphocyte ratio would also be associated with a persistent Thrombolysis In Myocardial Infarction flow grade of 0 after wire insertion in patients undergoing primary percutaneous coronary intervention. METHODS: A total of 644 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 12 hours of symptom onset were included in our study. Blood samples were drawn immediately upon hospital admission. The patients were divided into 3 groups according to their Thrombolysis In Myocardial Infarction flow grade: Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion, Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. RESULTS: The neutrophil-to-lymphocyte ratio was significantly higher in the group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion compared with the group with Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and the group with Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. The group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion also had a significantly higher in-hospital mortality rate. Persistent coronary no-flow after wire insertion was independently associated with the neutrophil-to-lymphocyte ratio. CONCLUSIONS: An increased neutrophil-to-lymphocyte ratio on admission is significantly associated with persistent coronary no-flow after wire insertion in patients with ST-segment ...

Analysis of predictive factors of intestinal obstruction in acute myocardial infraction patients afterprimary percutaneous coronary intervention / 中华急诊医学杂志

Objective to determine predictive factors of intestinal obstruction in acute myocardial infraction (AMI) patients after primary percutaneous coronary intervention (PCI) and to establish predictive model.Methods A total of 1220 AMI patients underwent primary PCI in Jiangxi provincial people's hospitalfrom June2004 toJune 2014were retrospectively analyzed.And 1025 cases of them whichall met the inclusion and exclusion criteriawere randomlydivided by using random number generated by SPSS 17.0 into two cohorts:model derivation cohort (MDC) and model validation cohort (MVC).MDC was divided into intestinal obstruction group and control group.predictive factors were identified using univariable andmultivariable logistic regression analysis in MDC.Interger point values were assigned to each predictor based upon their coefficient in multivariable logistic regression model to establish scoring model.The summed scores of each case in MVC were calculated to test predictive ability of the model by ROC cure.Results Total of 1 025 patients,103 patients were diagnosed with different types of intestinal obstruction and the incidence of intestinal obstruction was 10.0％.Low position intestinal obstruction,incomplete intestinal obstruction and simple intestinal obstructionwere main characteristics in these patients.logistic regression analysis identified ten risk factorscan predict the appearance of intestinal obstruction:age ＞ 65years old (OR =1.44,95％ CI:1.26-4.63,P =0.000),diabetes mellitus (OR =3.37,95％ CI:2.39-9.47,P =0.000),habitual constipation (OR =4.75,95 ％ CI:3.58-11.24,P =0.024),inferior and extensive anterior wall myocardial infarction (OR =2.16,95％ CI:1.94-4.79,P =0.017),cardiac functiongrade≥3 class (Killip classification) (OR=2.86,95％CI:1.98-5.67,P=0.002),femoral approach (OR=2.76,95％CI:1.38-6.12,P=0.002),K+ ＜3.5 mmol/L (OR=1.86,95％CI:1.11-5.47,P =0.005),taking laxative (OR =3.59,95％ CI:2.99-10.21,P =0.000),using morphine (OR =1.98,95％ CI:1.07-3.12,P =0.021) and estimated glomerular filtration rate (eGFR) ＜60 mL · min-1 · 1.73m-2 (OR =1.19,95％ CI:1.10-3.22,P =0.031).and areas under the ROC cure was 0.815 (95％ CI:0.802-0.883,P =0.000) and indicating the accuracy of predicting intestinal obstruction.Conclusions age ＞ 65 years old,diabetes mellitus,habitual constipation,inferior and extensive anterior parts of myocardial infarction,cardiac functiongrade ≥3class (Killip classification),femoral approach,K + ＜3.5mmol/L,taking laxative,using morphine and eGFR ＜ 60 ml.min-1.1.73m2 were important predictive factors for intestinal obstruction in AMI patients after underwent 0 and the scoring model can predict accurately intestinal obstruction in such patients.

Cardioprotective effects of gradual ischemic postconditioning in percutanous coronary intervention / 中国中西医结合急救杂志

Objective To observe the protective effect of gradual ischemic postconditioning (IP) capable of improving reperfusion on reperfusion injury in patients with ST-segment elevation acute myocardial infarction (STEAMl) undergoing primary percutaneous coronary intervention (PPCI).Methods 102 in-patients with STEAMI undergoing PPCI in the Department of Cardiology in the First People's Hospital of Kunshan City Affiliated to Jiangsu University from February 2011 to August 2014 were enrolled in this study. They were divided into three groups by a random number table: IP group (32 cases), gradual IP group (30 cases) and routine reperfusion group (40 cases). In IP group, after the opening of the infarction related blood vessel, ischemic postconditioning within the first minute of arterial reperfusion was made through three episodes of 1 minute inflation and 1 minute pressure withdrawn of an angioplasty balloon, and then persistent reperfusion was carried out. In the gradual IP group, the patients received three times of gradual angioplasty balloon inflation and denation, 1 minute/1minute, 30 seconds/30 seconds and 15 seconds/15 seconds respectively, presenting the gradual change of IP time. In the routine reperfusion group, after the opening of blocked blood vessel, the patients underwent routine PCI to persistently recover the coronary artery blood supply. The changes of related lead ST segment regression (Sum-STR), incidence of reperfusion arrhythmia, corrected thrombolysis in myocardial infarction (TIMI) franle count (CTFC), peaks of MB isoenzyme of creatine kinase (CK-MB), left ventricular ejection fraction (LVEF) and frequency of adverse events in follow-up period were compared among the three groups.Results The baseline characteristics were comparable in three groups. The incidence of ventricular premature beats was significantly lower in gradual IP group than that in routine reperfusion group [30.0% (9/30) vs. 55.0% (22/40),P 0.05). The incidence of ventricular tachycardia was significantly lower in IP and gradual IP groups than that in routine reperfusion group [15.6% (5/32), 13.3% (4/30) vs. 40.0% (16/40), bothP 0.05). In IP group and gradual IP group, the Sum-STR incidence, CTFC, CK-MB peaks were lower than those of routine reperfusion group [Sum-STR: (56.7±18.3)%, (57.3±21.5)% vs. (44.6±21.6)%; CTFC: 25.47±5.37, 24.46±6.41 vs. 31.62±7.56; CK-MB peaks (U/L): 126.3±78.5, 121.6±82.5 vs. 147.4±72.5; allP 0.05). In routine reperfusion group, one patient died because the ventricular fibrillation could not be corrected and another one died of no-reflow during operation. Each group had 1 patient died during the 4 weeks of follow-up after operation, in the routine reperfusion group, one died of refractory heart failure, and the cause of death of other two patients, one in IP group and another in gradual IP group, was considered due to subacute thrombosis in stent. Major bleeding events were not found in each group.Conclusion Gradual IP can ameliorate myocardial reperfusion injury more significantly in patients with STEAMI undergoing PPCI.

A reseach on large dosage of tilofiban injection into coronary artery in patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention / 中国中西医结合急救杂志

Objective To discuss the effect and safety about large dosage of tilofiban injection into coronary artery in patients with ST-segment elevated myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods A prospective study was conducted. Two hundred and eighteen patients with STEMI admitted into Cardiology Department of Taizhou Central Hospital were enrolled. According to the difference in dosage, they were divided into a large dosage tilofiban group (102 cases) and a routine dosage tilofiban group (116 cases). In both groups, they received the injection of load dosage of tilofiban into coronary artery during they underwent primary PCI, the load dosage being 25μg/kg in the large dosage group, and 10μg/kg in the routine dosage group. Afterwards, the dosage was kept on 0.15μg·kg-1·min-1 in both groups lasting for 18-24 hours. The flow of thrombolysis in myocardial infarction (TIMI) immediately after PCI, the return of ST-segment after operation for 2 hours, the rate of bleeding events, the rate of major adverse cardiac event [MACE, including death, re-infarction and target vessel revascularization (TVR)] and prognosis after operation for 30 days were observed. Results The ratios of the immediate reflow of TIMI 3 grade after operation and the return of ST-segment after operation for 2 hours in the large dosage tirofiban group were higher than those in the routine dosage tirofiban group [the ratio of the reflow of TIMI 3 grade:92.16%(94/102) vs. 81.90%(95/116), the ratio of the return of ST-segment after operation for 2 hours:89.22%(91/102) vs. 73.28%(85/116), both P 0.05]. Conclusion The injection of a large dosage of tilofiban into a coronary artery in patients with STEMI undergoing primary PCI is an effective and safe method to allow them to get more clinical benefits.