Incidência e fatores de risco associados ao infarto agudo do miocárdio sem obstrução coronariana / Incidence and risk factors associated with acute myocardial infarction with nonobstructive coronary arteries / Incidencia y factores de riesgo associados al infarto agudo de miocardio sin obstrucción coronaria

Objetivo: identificar a incidência, fatores de risco e desfechos associados ao infarto agudo do miocárdio sem obstrução de artérias coronárias (myocardial infarction with nonobstructive coronary arteries ­ MINOCA). Método: estudo de coorte prospectivo em prontuários clínicos num hospital terciário do extremo Sul catarinense. Foram incluídos pacientes diagnosticados com infarto agudo do miocárdico (IAM) submetidos a estudo hemodinâmico nos anos de 2017 e 2018. Resultados: ao analisar 445 prontuários, observou-se a ocorrência de MINOCA em 28 pacientes (6,3%). Comparando o grupo MINOCA com o grupo IAM obstrutivo, os pacientes do grupo MINOCA eram mais jovens, com média de 54 anos (DP ± 14; p=0,007), tinham menor incidência de tabagismo (2 versus 156, p<0,001), hipertensão arterial (10 versus 242; p=0,002), menor tempo médio (dias) de internação hospitalar (5,79 ± 3,05 versus 7,49 ± 5,20; p= 0,02) e menos admissões em unidade de tratamento intensivo (5 versus 212; p=0,002). Conclusão: a incidência de MINOCA estimada dentre o total de IAM no Sul de Santa Catarina foi de 6,3% [IC 95]. Os pacientes do grupo MINOCA tiveram menor prevalência de comorbidades, melhor evolução intra-hospitalar e melhor desfecho.

Objective: to identify the incidence, risk factors and outcomes associated with myocardial infarction with nonobstructive coronary arteries (MINOCA). Method: it is a with prospective cohort study data collection from medical records data. Patients with acute myocardial infarction (AMI) that went through hemodynamic study in 2017 and 2018 were included. Results: when analyzing 445 medical records, the occurrence of MINOCA was observed in 28 patients (6.3%). Comparing the MINOCA group with the obstructive AMI group, patients in the MINOCA group were younger, with a mean age of 54 years (SD ± 14; p=0.007), had a lower incidence of smoking (2 versus 156, p<0.001), hypertension (10 versus 242; p=0.002), shorter mean length of hospital stay (days) (5.79 ± 3.05 versus 7.49 ± 5.20; p= 0.02) and fewer admissions to intensive care unit (5 versus 212; p=0.002). Conclusion: the estimated incidence of MINOCA among the total number of AMI in southern Santa Catarina was 6.3% [CI 95]. Patients in the MINOCA group had a lower prevalence of comorbidities, better in-hospital evolution and better outcome.

Risk factors related to coronary artery occlusion in female patients with ischemic angina pectoris / 中华心血管病杂志

Objective: To analyze the risk factors of coronary artery occlusion in female patients with ischemic angina pectoris. Methods: Clinical data of 1 600 patients (666 females and 934 males) who underwent coronary angiography from January 2013 to December 2015 due to angina pectoris in 6 major coronary intervention centers in China were retrospectively analyzed. The clinical characteristics were compared between the female and male groups, and between the non-obstructive coronary artery disease (INOCA) and ischemic obstructive coronary artery disease (IOCA) subgroups of female subjects with angina pectoris. The risk factors related to the degree of coronary artery occlusion in female patients were analyzed. Results: In the enrolled patients who underwent coronary angiography for angina pectoris, female group was older than the male group, and the proportion of patients with hypertension, diabetes and ischemia accompanied by IOCA was significantly higher than that of the male group (P<0.05). Univariate analysis showed that age≥65 years, hypertension, diabetes, and typical angina symptoms were associated with an increased risk of IOCA in female patients with angina pectoris. Multivariate regression analysis showed that age≥65 years old (OR=1.784, 95%CI: 1.146-2.776, P=0.010), hypertension (OR=1.782, 95%CI: 1.201-2.644, P=0.004) and typical angina symptoms (OR=1.642, 95%CI: 1.127-2.393, P=0.010) were independent risk factors for female patients with angina pectoris diagnosed as IOCA. The correlation analysis between the number of risk factors and the type of coronary artery disease obstruction showed that the incidence of INOCA decreased significantly with the increase of the number of risk factors, from 45.5% to 14.2%. The incidence of IOCA increased significantly with the number of risk factors, from 54.5% to 85.8% (P for trend<0.001). Conclusion: The incidence of INOCA in female patients with angina pectoris suspected of coronary heart disease is higher than that of male. The incidence of IOCA increased significantly, and the incidence of INOCA decreased significantly in proportion to the increase of the number of combined risk factors.

Effect of complete percutaneous revascularization on improving long-term outcomes of patients with chronic total occlusion and multi-vessel disease / 中华医学杂志(英文版)

BACKGROUND@#Limited data are available on the comparison of clinical outcomes of complete vs. incomplete percutaneous coronary intervention (PCI) for patients with chronic total occlusion (CTO) and multi-vessel disease (MVD). The study aimed to compare their clinical outcomes.@*METHODS@#A total of 558 patients with CTO and MVD were divided into the optimal medical treatment (OMT) group ( n = 86), incomplete PCI group ( n = 327), and complete PCI group ( n = 145). Propensity score matching (PSM) was performed between the complete and incomplete PCI groups as sensitivity analysis. The primary outcome was defined as the occurrence of major adverse cardiovascular events (MACEs), and unstable angina was defined as the secondary outcome.@*RESULTS@#At a median follow-up of 21 months, there were statistical differences among the OMT, incomplete PCI, and complete PCI groups in the rates of MACEs (43.0% [37/86] vs. 30.6% [100/327] vs. 20.0% [29/145], respectively, P = 0.016) and unstable angina (24.4% [21/86] vs. 19.3% [63/327] vs. 10.3% [15/145], respectively, P = 0.010). Complete PCI was associated with lower MACE compared with OMT (adjusted hazard ratio [HR] = 2.00; 95% confidence interval [CI] = 1.23-3.27; P = 0.005) or incomplete PCI (adjusted HR = 1.58; 95% CI = 1.04-2.39; P = 0.031). Sensitivity analysis of PSM showed similar results to the above on the rates of MACEs between complete PCI and incomplete PCI groups (20.5% [25/122] vs. 32.6% [62/190], respectively; adjusted HR = 0.55; 95% CI = 0.32-0.96; P = 0.035) and unstable angina (10.7% [13/122] vs. 20.5% [39/190], respectively; adjusted HR = 0.48; 95% CI = 0.24-0.99; P = 0.046).@*CONCLUSIONS@#For treatment of CTO and MVD, complete PCI reduced the long-term risk of MACEs and unstable angina, as compared with incomplete PCI and OMT. Complete PCI in both CTO and non-CTO lesions can potentially improve the prognosis of patients with CTO and MVD.

Sobrevida a largo plazo de pacientes con infarto agudo del miocardio en presencia de oclusiones crónicas totales en vaso no culpable / Prognostic value of the presence of a chronic total occlusion in patients with acute myocardial infarction

BACKGROUND: The presence of a chronic total occlusion (CTO) in a non-infarct-related artery in patients with acute myocardial infarction (AMI), may be a sign of bad prognosis. AIM: To estimate the long-term survival of patients with AMI who were studied with coronarography during 2013-2014 who had one or more CTO in a non-infarct-related artery. MATERIAL AND METHODS: Review of coronary angiograms performed between 2013 and 2014 to patients with an AMI. Patients were grouped as having or not a CTO in a non-infarct-related artery. Their medical records were reviewed, and mortality was determined requesting their death certificates. RESULTS: Of 993 patients with AMI under-going coronarography, 233 (23.5%) had at least one CTO. Patients with CTO were older (66 and 62 years respectively). They also had a higher prevalence of hypertension, diabetes mellitus (DM), kidney failure and moderate to severe systolic ventricular dysfunction. The independent predictors of mortality were CTO, age, DM and kidney failure. Survival at an average follow-up period of 57 months was significantly higher in patients without CTO (89.5 and 80.3% respectively, p < 0.01). CONCLUSIONS: The presence of CTO in patients with acute myocardial infarction is associated with a higher frequency of cardiovascular risk factors and lower long-term survival.

Predictive value of SYNTAX-Ⅱ score on prognosis of patients with chronic total occlusion undergoing percutaneous coronary intervention / 中华心血管病杂志

Objective: To investigate the predictive value of SYNTAX-Ⅱ score on long term prognosis of patients diagnosed with chronic total occlusion (CTO) and received percutaneous coronary intervention (PCI). Methods: Patients undergoing CTO-PCI in Fuwai hospital from January 2010 to December 2013 were enrolled in this retrospective analysis. The SYNTAX-Ⅱ score of the patients was calculated. According to SYNTAX-Ⅱ score tertiles, patients were stratified as follows: SYNTAX-Ⅱ≤20, 20<SYNTAX-Ⅱ≤27, SYNTAX-Ⅱ>27. Primary endpoint was major adverse cardiac events (MACCE), including all-cause death, myocardial infarction, stroke and any revascularization. Secondary endpoints included stent thrombosis, heart failure and target lesion failure (TLF). Patients were followed up by outpatient visit or telephone call at 1 month, 6 months and 1 year after PCI, and annually up to 5 years. Multivariate Cox regression model was used to analyze the independent risk factors of all-cause death in patients undergoing CTO-PCI. The predictive value of SYNTAX score with SYNTAX-Ⅱ score for all-cause death was evaluated by the receiver operating characteristic (ROC) curve and the area under the curve (AUC). Results: A total of 2 391 patients with CTO and received PCI were enrolled in this study. The mean age was (57.0±10.5) years, 1 994 (83.40%) patients were male. There were 802 patients in lower tertile group (SYNTAX-Ⅱ≤20), 798 patients in intermediate group (20<SYNTAX-Ⅱ≤27) and 791 patients in upper tertile group (SYNTAX-Ⅱ>27). At the end of 5-year follow-up, the loss to follow-up rate of the three groups was 9.10%(73/802), 10.78%(86/798)and 8.85%(70/791), respectively. The rate of all-cause mortality (1.78% (13/729) vs. 3.65% (26/712) vs. 9.02% (65/721), P<0.001), cardiac death (1.37% (10/729) vs. 2.11% (15/712) vs. 4.85% (35/721), P<0.001), target vessel myocardial infarctions (4.25% (31/729) vs. 4.49% (32/712) vs. 7.07% (51/721), P=0.03), probable stent thrombosis (1.51% (11/729) vs. 2.81% (20/712) vs. 3.61% (26/721), P=0.04) and heart failure (1.78% (13/729) vs. 1.97% (14/712) vs. 5.41% (39/721), P<0.001) increased in proportion to increasing SYNTAX-Ⅱ score (all P<0.05). Multivariable Cox regression analysis indicated that female (HR=2.05, 95%CI 1.12-3.73, P=0.01), left ventricular ejection fraction (HR=0.97, 95%CI 0.95-1.00, P=0.05) and SYNTAX-Ⅱ score (HR=1.07, 95%CI 1.02-1.11,P=0.01) were independent predictors for all-cause mortality in patients undergoing CTO-PCI. The predicted value of the SYNTAX-Ⅱ score for all-cause death was significantly higher than the SYNTAX score (AUC 0.71 vs. 0.60, P=0.003). Conclusion: For CTO patients who underwent percutaneous coronary intervention, SYNTAX-Ⅱ score is an independent predictor for 5-year all-cause death, and SYNTAX-Ⅱ serves as an important predictor for all-cause death in these patients.

Associação entre os Níveis Séricos de Elabela e Oclusão Total Crônica em Pacientes com Angina Pectoris Estável / Association Between Serum Elabela Levels and Chronic Totally Occlusion in Patients with Stable Angina Pectoris

Resumo Fundamento: Os efeitos benéficos do elabela no sistema cardiovascular foram demonstrados em estudos. Objetivo: Comparar os níveis séricos de elabela de pacientes com oclusão total crônica (OTC) com pacientes controle com artérias coronárias normais e investigar se há correlação com o desenvolvimento colateral. Métodos: Estudo transversal e prospectivo. O estudo incluiu cinquenta pacientes (28,0% mulheres, idade média 61,6±7,3 anos) com OTC em pelo menos um vaso coronário e 50 pacientes (38% mulheres, idade média 60,7±6,38 anos) com artérias coronárias normais. Os pacientes do grupo OTC foram divididos em dois grupos: Rentrop 0-1, composto por pacientes com fraco desenvolvimento colateral e Rentrop 2-3, composto por pacientes com bom desenvolvimento colateral. Além da idade, sexo, características demográficas e exames laboratoriais de rotina dos pacientes, foram medidos os níveis de elabela. Resultados: As características demográficas e os valores laboratoriais mostraram-se semelhantes em ambos os grupos. Ao passo que o nível médio de NT-proBNP e troponina estava maior no grupo OTC, o nível médio de elabela estava menor (p<0,05 para todos). Na análise de regressão multivariada, os níveis de NT-proBNP e elabela foram considerados preditores independentes para OTC. Além disso, o nível de elabela apresentou-se estatisticamente maior em pacientes do grupo Rentrop 2-3 em comparação com os pacientes do grupo Rentrop 0-1 (p<0,05). Conclusões: Em nosso estudo, mostramos que o nível médio de elabela estava baixo em pacientes com OTC em comparação com pacientes normais. Além disso, constatamos que o nível de elabela é inferior em pacientes com desenvolvimento colateral fraco em comparação com pacientes com bom desenvolvimento colateral. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background: The beneficial effects of Elabela on the cardiovascular system have been shown in studies. Objective: To compare serum Elabela levels of chronic total occlusion (CTO) patients with control patients with normal coronary arteries, and to investigate whether there is a correlation with collateral development. Methods: The study was planned cross-sectionally and prospectively. Fifty patients (28.0% female, mean age 61.6±7.3years) with CTO in at least one coronary vessel and 50 patients (38% female, mean age 60,7±6.38 years) with normal coronary arteries were included in the study. Patients in the CTO group were divided into two groups as Rentrop 0-1, those with weak collateral development, and Rentrop 2-3 with good collateral development. In addition to the age, sex, demographic characteristics and routine laboratory tests of the patients, Elabela levels were measured. Results: Demographic characteristics and laboratory values were similar in both groups. While the mean NT-proBNP and troponin were higher in the CTO group, the Elabela mean was lower (p <0.05 for all). In the multivariate regression analysis, NT-proBNP and Elabela levels were found to be independent predictors for CTO. Also, Elabela level was found to be statistically higher in Rentrop class 2-3 patients compared to Rentrop class 0-1 patients (p<0.05). Conclusion: In our study, we showed that the average Elabela level was low in CTO patients compared to normal patients. In addition, we found the level of Elabela to be lower in patients with weak collateral development compared to patients with good collateral development. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Factores asociados a la nefropatía inducida por medios de contraste en pacientes con oclusión coronaria significativa / Contrast-induced nephropathy associated factors in patients with significant coronary obstruction

El intervencionismo coronario se asocia a la aparición de nefropatía inducida por contraste. El propósito del estudio fue evaluar el riesgo de desarrollar nefropatía inducida por contraste (NIC) en pacientes con obstrucción coronaria significativa y su relación con factores de riesgo conocidos para esta nefropatía. Se diseñó un estudio de cohorte prospectiva con 160 pacientes atendidos en el cardiocentro del hospital "Hermanos Ameijeiras", Cuba, a los cuales se les realizó una coronariografía invasiva, entre enero 2016 y julio 2017. La edad promedio fue de 61,6 ± 9,2 años; el 70,6% eran hombres. Predominaron los antecedentes patológicos personales de cardiopatía isquémica (85,6%), y de hipertensión arterial (75,6%). El 75% de los casos presentó una oclusión coronaria significativa. La frecuencia de nefropatía por contraste fue de 42,5%. Los factores que guardaron importante relación estadística con la presencia de oclusión arterial significativa fueron la cardiopatía isquémica conocida (p<0,001), el intervencionismo coronario percutáneo previo (p=0,007), la creatinina después (p=0,043) y la NIC (p=0,016) así como el volumen de contraste administrado (p=0,006). En el subgrupo de pacientes con oclusión significativa el hematocrito bajo (p=0,025) y el intervencionismo coronario percutáneo de urgencia (p=0,007) fueron los factores más influyentes. Se concluye que los pacientes con oclusión coronaria significativa tienen un riesgo aumentado para el desarrollo de la nefropatía por contraste. La corrección de aquellos factores de riesgo que sean modificables (como el hematocrito bajo) y la correcta aplicación del protocolo de hidratación son esenciales para prevenir esta complicación.

Coronary intervention is associated with the appearance of contrast-induced nephropathy. The purpose of the study was to assess the risk of developing contrast-induced nephropathy in patients with significant coronary obstruction and its relationship with known risk factors for this nephropathy. A prospective cohort study was designed with 160 patients treated at the cardiocenter of the "Hermanos Ameijeiras" hospital, Cuba, who underwent invasive coronary angiography, between January 2016 and July 2017. The average age was 61.6 ± 9 ,2 years; 70.6% were men. The personal pathological history of ischemic heart disease (85.6%) and arterial hypertension (75.6%) predominated. 75% of the cases presented a significant coronary occlusion. The frequency of contrast nephropathy was 42.5%. The factors that had an important statistical relationship with the presence of significant arterial occlusion were known ischemic heart disease (p <0.001), previous percutaneous coronary intervention (p = 0.007), creatinine after the procedure (p = 0.043) and CIN (p = 0.016) as well as the volume of contrast administered (p = 0.006). In the subgroup of patients with significant occlusion, low hematocrit (p = 0.025) and emergency percutaneous coronary intervention (p = 0.007) were the most influential factors. It is concluded that patients with significant coronary occlusion have an increased risk for the development of contrast nephropathy. The correction of those risk factors that are modifiable (such as low hematocrit) and the correct application of the hydration protocol are essential to prevent this complication

Sgarbossa Criteria in Left Bundle Branch Block in a Hypertensive Emergency, a Case Report

Abstract Left bundle branch block and hypertensive emergency are very common conditions in clinical cardiovascular and emergency practice. Hypertensive emergency encompasses a spectrum of clinical presentations in which uncontrolled blood pressure leads to progressive end-organ dysfunction. Suspected acute myocardial infarction in the setting of a left bundle branch block presents a unique diagnostic and therapeutic challenge to the clinician. The diagnosis is especially difficult due to electrocardiographic changes caused by altered ventricular depolarization. However, reports on the use of the Sgarbossa's criteria during the management of hypertensive emergency are rare. My current case is a hypertensive emergency patient with acute chest pain and left bundle branch block. Sgarbossa's criteria were initially very weak and, over time, became highly suggestive of acute ST-segment elevation myocardial infarction. Interestingly, chest pain increased as the Sgarbossa's diagnostic criteria were met. Here, we present a case of developing ST-segment elevation myocardial infarction with left bundle branch block that is indicating for thrombolytic therapy. Thrombolytic therapy was strongly indicated because of a higher developing of Sgarbossa criteria scoring. Thus, the higher Sgarbossa criteria scoring in the case was the only indication for thrombolytic. Therefore, how did Sgarbossa criteria developing during the course of the case to indicating the need for thrombolytic therapy?

Clinical value of left ventricular strain analysis by cardiovascular magnetic resonance in patients with coronary chronic total occlusion / 中华心血管病杂志

Objective: To explore the clinical value of quantitatively assessment of left ventricular strain in patients with coronary chronic total occlusion (CTO) by cardiac magnetic resonance imaging (CMR)-feature tracking (CMR-FT) technique. Methods: In this retrospective and observation study, patients with single CTO, who underwent CMR examination in Beijing Anzhen Hospital from November 2014 to January 2019, were selected as case group (CTO group), and those without cardiovascular diseases defined by echocardiography, electrocardiogram (ECG) and clinical history and with normal CMR results were selected as healthy control group (control group). General clinical data including age, gender, discharge diagnosis, and the examination results of echocardiography and ECG were obtained from the electronic medical record system. Two-dimensional CMR-FT was applied to measure left ventricle (LV) global peak radial, circumferential, and longitudinal strains (GPRS, GPCS and GPLS, respectively), and the regional myocardial strain in the target vessel area of CTO was analyzed. Grayscale thresholds of 5 standard deviations (SDs) were used to quantify late gadolinium enhancement (LGE). Patients with CTOs were divided into infract size>10% group and infarct size≤10% group, and left ventricular ejection fraction (LVEF)≥50% group and LVEF<50% group, respectively. The differences between various groups were compared. Results: There were 52 patients in CTO group (34 males, age (54.1±11.7) years, body mass index (BMI) (26.2±2.5)kg/m2) and 30 patients in control group (14 males, age(51.6±12.3)years, BMI (25.6±3.3)kg/m2). There was no significant difference in age, gender, and BMI between the two groups (all P>0.05). LVEF, GPRS, GPCS and GPLS were significantly lower in CTO group than in control group (all P<0.05), left ventricular volume (LVEDV) was similar between the two groups (P>0.05). Among the patients with CTO, there were 26 patients with infarct size>10% and 26 patients with infarct size≤10%. GPRS, GPCS and GPLS were significantly lower (all P<0.05), while LVEF and LVEDV were similar in CTO patients with infarct size≤10% as compared to control group (both P>0.05). LVEF, GPRS, GPCS and GPLS were significantly lower (all P<0.05), while LVEDV was similar in CTO patients with infarct size>10% (P>0.05) as compared to control group. GPRS and GPCS were significantly lower (both P<0.05), while LVEF, LVEDV and GPLS were similar in CTO patients with infarct size>10% as compared to infarct size≤10% group. There were 40 subjects in LVEF≥50% group and 12 subjects in LVEF<50% group. Compared with the control group, GPCS and GPLS of CTO patients were significantly lower in LVEF≥50% group and LVEF<50% group (all P<0.01), LVEF and LVEDV was similar in CTO patients with LVEF≥50% (both P>0.05), but LVEF was lower and LVEDV was larger in LVEF<50% group (both P<0.05). The GPRS, GPCS, GPLS and LVEF of CTO patients in LVEF ≥ 50% group were higher than those in LVEF<50% group (all P<0.0l), and the myocardial infarction size was smaller than that in LVEF reduced group (P<0.0l), but there was no significant difference in LVEDV between the two groups (P=0.07). In the CTO group, there were 21 patients with left anterior descending artery (LAD) occlusion and 126 segments supplied by the target vessels. The peak radial strain (PRS), circumferential strain (PCS) and longitudinal strain (PLS) in the blood supply area were lower than those in the control group (all P<0 01). In 7 patients with left circumflex artery (LCX) occlusion, the number of myocardial segments supplied by the target vessels was 35, and the PRS, PCS and PLS in the target vessel supply area were lower than those in the control group (all P<0 05). In 24 patients with right coronary artery (RCA) occlusion, the number of myocardial segments supplied by the target vessels was 120, and the PRS, PCS and PLS in the target vessel supply area were lower than those in the control group (all P<0.01). Among the 126 segments in 21 patients with LAD CTO, 91 (72.2%) segments had infarct size≤25%, 17 (13.5%) segments had infarct size between 26%-50%, 11 segments (8.7%) had infarct size between 51%-75%, and 7 (5.6%) segments had infarct size between 76%-100%. Among the 35 segments in 7 patients with LCX CTO, 31 (88.6%) segments had infarct size≤25%, and 4 (11.4%) segments had infarct size between 26%-75%. Among the 120 segments in 24 patients with RCA CTO, 96 (80.0%) segments had infarct size≤25%, 11 (9.2%) segments had infarct size between 26%-50%, 8 (6.7%) segments had infarct size between 51%-75%, and 5 segments (4.2%) had infarct size between 76%-100%. Conclusions: In this study with single CTO, although the LVEF is preserved in the majority of the patients, the left ventricular global and regional strain values are significantly decreased. The larger the infarct size, the greater the impact on radial and circumferential motion, reflecting the early impairment of left ventricular function in these patients.

The acute and long-term outcome of patients with ST segment elevation myocardial infarction concurrent with chronic total occlusion / 中华心血管病杂志

Objective: To evaluate the acute and long-term outcome of patients with ST segment elevation myocardial infarction (STEMI) concurrent with chronic total occlusion (CTO) undergoing primary percutaneous coronary intervention (PCI). Methods: 11 905 STEMI patients from the China Acute Myocardial Infarction Registry were enrolled in this study and divided into CTO group and non-CTO group according to the angiography results of primary PCI. 1∶3 propensity score matching was used to match the patients between the two groups. The primary endpoint was in-hospital mortality and mortality at 1-year post PCI. The secondary endpoint was major adverse cardiovascular events (MACE) including death, re-myocardial infarction, revascularization, heart failure associated readmission, stroke and major bleeding at 1-year post PCI. Results: There were 931 CTO patients (7.8%) in this cohort (male=755 (81.1%), mean age (62.2±11.4 years)). The rest 10 974 patients were STEMI without CTO (male=8 829 (80.5%),mean age (60.0±11.8) years). After propensity score matching, 896 patients were enrolled in CTO group and 2 688 in non-CTO group. In-hospital mortality was significantly higher in the CTO group than in non-CTO group (4.2% vs. 2.4%, P=0.006). The ratio of all cause death, cardiac death, and MACE at 1-year follow up was also significantly higher in the CTO group than in non-CTO group (8.5% vs. 4.4%, P<0.001, 5.3% vs. 2.6%, P=0.001, 35.1% vs. 23.3%, P<0.001, respectively). Multiple regression analysis showed that CTO (HR=1.54, 95%CI 1.06-2.22, P=0.022), advanced age (HR=1.06, 95%CI 1.04-1.08, P<0.001), and previous heart failure history (HR=4.10, 95%CI 1.90-8.83, P<0.001) were independent risk factors of 1-year mortality. Conclusions: The in-hospital and 1-year mortality increased significantly in STEMI patients concurrent with CTO. CTO, advanced age and history of heart failure are independent risk factors of 1-year death among STEMI patients.

Manejo del Infarto Agudo de Miocardio con elevación de ST en pacientes adultos de la Unidad Técnica de Cardiología del HECAM / Management of ST elevation Acute Myocardial Infarction in adult patients of the Technical Unit of Cardiology of HECAM

INTRODUCCIÓN: La enfermedad isquémica cardiaca es la pri-mera causa de muerte a nivel mundial. A pesar de no tener estadísticas certeras, Amé-rica Latina incurre en la tendencia de un au-mento en la mortalidad por enfermedad car-diovascular; una de las probables causas es la rápida urbanización que ha sido asociada a mayor exposición de riesgo cardiovas-cular1. Es sabido que la única medida efec-tiva para preservar la función ventricular y disminuir la mortalidad, reinfarto y acci-dente cerebrovascular es la apertura rápida de la arteria culpada para reestablecer el flujo coronario2.

INTRODUCTION: Ischemic heart disease is the leading cause of death worldwide. Despite not having ac-curate statistics, Latin America incurs the trend of an increase in mortality from car-diovascular disease; one of the probable causes is rapid urbanization that has been associated with greater exposure to car-diovascular risk1. It is known that the only effective measure to preserve ventricular function and reduce mortality, reinfarction and stroke is the rapid opening of the culprit artery to reestablish coronary flow2.

Long-term outcomes of percutaneous coronary intervention for in-stent chronic total occlusion / 中华医学杂志(英文版)

BACKGROUND@#The development of the technique has improved the success rate of percutaneous coronary intervention (PCI) for in-stent chronic total occlusion (IS-CTO). However, long-term outcomes remain unclear. The present study sought to investigate long-term outcomes of PCI for IS-CTO.@*METHODS@#A total of 474 IS-CTO patients were enrolled at two cardiac centers from 2015 to 2018 retrospectively. These patients were allocated into either successful or failed IS-CTO PCI groups. The primary endpoint (major adverse cardiac events [MACE]) consisted of recurrent angina pectoris (RAP), target-vessel myocardial infarction (MI), heart failure, cardiac death, or ischemia-driven target-vessel revascularization (TVR) at follow-up. Multivariable Cox regression analysis was used to investigate the association between treatment appropriateness and clinical outcomes.@*RESULTS@#A total of 367 patients were successfully treated with IS-CTO PCI while 107 patients had failed recanalization. After a median follow-up of 30 months (interquartile range: 17-42 months), no significant difference was observed between the two groups for the following parameters: cardiac death (successful PCI vs. failed PCI: 0.9% vs. 2.7%; adjusted hazard ratio [HR]: 1.442; 95% confidence interval [CI]: 0.21-9.887; P = 0.709), RAP (successful PCI vs. failed PCI: 40.8% vs. 40.0%; adjusted HR: 1.025; 95% CI: 0.683-1.538; P = 0.905), heart failure (successful PCI vs. failed PCI: 6.1% vs. 2.7%; adjusted HR: 0.281; 95% CI: 0.065-1.206; P = 0.088), target-vessel related MI (successful PCI vs. failed PCI: 1.5% vs. 2.7%; adjusted HR: 1.150; 95% CI: 0.221-5.995; P = 0.868), MACE (successful PCI vs. failed PCI: 44.2% vs. 45.3%; adjusted HR: 1.052; 95% CI: 0.717-1.543; P = 0.797). More patients were free of angina in the successful IS-CTO PCI group compared with failed PCI in the first (80.4% vs. 60%, P 18 months of dual antiplatelet therapy (DAPT) was an independent predictor of decreased risk of TVR (HR: 2.682; 95% CI: 1.295-5.578; P = 0.008) or MACE (without TVR) (HR: 1.898; 95% CI: 1.036-3.479; P = 0.038) in successful IS-CTO PCI.@*CONCLUSIONS@#After a median follow-up of 30 months, the successful IS-CTO PCI group had MACE similar to that of the failed PCI group. However, the successful IS-CTO PCI group had improved angina symptoms and were free from requiring coronary artery bypass grafting in the first or second years. To decrease MACE, DAPT was found to be essential and recommended for at least 18 months for IS-CTO PCI.

Clinical outcomes of opening coronary chronic total occlusion lesions with the assistance of BridgePoint devices / 中华心血管病杂志

Objective: To investigate the safety, efficacy and prognosis of antegrade dissection re-entry (ADR) with the assistance of BridgePoint devices in opening coronary chronic total occlusion (CTO). Methods: A total of 87 consecutive patients, who underwent percutaneous coronary intervention using BridgePoint devices from April 2016 to December 2018 in Xijing Hospital, were included in this study. General information of the selected patients, features of CTO lesions and intraoperative parameters were recorded. Short-term outcomes including technical success rate (defined as achieving TIMI 3 blood flow with residual stenosis<30%), surgical success rate (defined as no major adverse cardiovascular events (MACE) occured while hospitalized), complications, and MACE during hospitalization were observed. MACE included death, recurrent myocardial infarction, target vascular reconstruction (TVR) and cardiac tamponade. Patients were followed up by outpatient or telephone visits at 30 days and 6, 12, 24 and 36 months after discharge. Results: Eighty-seven patients, aged (61±10) years with J-CTO scores (2.49±0.52) were included, and 75(86%) were male. Six patients underwent direct ADR with BridgePoint system, and all were successful. Eighty-one patients underwent rescue ADR using BridgePoint devices, and 62 of them were successful. The success rate of ADR with BridgePoint devices was 78.2% (68/87). Nine out of the 19 failed cases succeeded after the application of rescue antegrade/retrograde technique. The technical success rate was 88.5% (77/87). Coronary perforation occurred in 2 cases (2.3%), one case was treated with covered stent and the other case with tamponade was treated with pericardiocentesis. One patient developed periprocedural myocardial infarction, and one patient suffered from sudden death, and one patient had cardiac tamponade. In-hospital MACE occurred in 3 (3.4%) patients. The surgical success rate was 85.1% (74/87).The procedure time was (175±72)minutes and the amount of contrast used was (449±155)ml. During a follow-up of 17(11, 26) months, the incidence of MACE within 30 days was 4.7% (4/86), while 10.5% (9/86) within 6 months, 17.4% (15/86) within 17 months. Conclusion: Opening CTO with the assistance of BridgePoint devices is feasible and safe, with high success rate and satisfactory outcome.

de Winter syndrome, an easily ignored but life-threatening disease: a case report / 浙江大学学报·医学版

de Winter syndrome is a special equivalent of anterior ST-segment elevation myocardial infarction (STEMI) characterized by the absence of overt ST-elevation with upsloping ST-segment depression followed by tall symmetrical T-waves in the precordial leads, often associated with total occlusion of the proximal left anterior descending coronary artery. Herein we present a case of de Winter syndrome in a 63-year-old man, whose initial ECG showed no ST-segment elevation, but subsequent coronary angiography confirmed total occlusion of the proximal LAD coronary artery. The patient was successfully treated via mechanical reperfusion therapy and stenting through percutaneous coronary intervention (PCI). de Winter syndrome is associated with a high mortality often due to insufficient awareness of this condition by clinicians. Immediate reperfusion therapy by PCI is the life-saving treatment for the patients diagnosed with this syndrome, and prompt recognition of the ECG pattern is critical to ensure the timely administration of the therapy.

Outcomes of chronic total occlusions in coronary arteries according to three therapeutic strategies: a meta-analysis with 6985 patients from 8 published observational studies

Abstract Objective: To perform a systematic review and meta-analysis of studies comparing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and medical treatment (MT) in patients with chronic total occlusions (CTOs). Methods: We identified eligible observational studies published in the China National Knowledge Infrastructure database, PubMed, Excerpta Medica database, Google Scholar, Cochrane Library, Web of Science, and "Clinical trials" registration from 1999 to October 2018. Main outcome measures were all-cause mortality, cardiac death, major adverse cardiac events (MACEs), and myocardial infarction (MI). Results: There were eight observational studies including 6985 patients. Patients' mean age was 64.4 years. Mean follow-up time was 4.3 years. Comparing with MT (2958 patients), PCI (3157 patients) presented decreased all-cause mortality (odd ratio [OR]: 0.46, 95% confidence interval [CI]: 0.36-0.60; P<0.001), cardiac death (OR: 0.40, 95% CI: 0.31-0.52; P<0.001), MACE (OR: 0.55, 95% CI: 0.43-0.71; P<0.001), and MI (OR: 0.40, 95% CI: 0.26-0.62; P<0.001). Comparing with MT, CABG (613 patients) presented lower all-cause mortality (OR: 0.50, 95% CI: 0.36-0.69; P<0.001) and MACE (OR: 0.50, 95% CI: 0.26-0.96; P=0.04), but not lower MI (OR: 0.23, 95% CI: 0.03-1.54; P=0.13) and cardiac death (OR: 0.83, 95% CI: 0.51-1.35). Comparing with CABG, PCI did not present decreased risk for those outcomes. Conclusions: PCI or CABG was associated with better clinical outcome in patients with CTO than MT. PCI is not better than CABG in decreasing mortality, MI, cardiac death, and MACE in coronary CTO patients.

A complete occlusion of right coronary artery due to stanford type a aortic dissection - successful treatment with extracorporeal membrane oxygenation (ecmo)

Abstract We present a patient diagnosed Stanford Type A aortic dissection, who was misdiagnosed as acute myocardial infarction for 5 days. In the surgery, the right coronary ostium was totally occluded, and the right coronary artery (RCA) was bluish from the trunk to branches. The true lumen couldn't be found when we opened the RCA. We had to give up coronary artery bypass grafting (CABG). After a regular surgery of type A aortic dissection, the patient was failed to wean from cardiopulmonary bypass due to the right heart dysfunction. The Extracorporeal membrane oxygenation (ECMO) was instituted. The right ventricular wall motion was gradually improved during the post-operation period. This is the first report of using ECMO to successfully treat a complete occlusion of the right coronary artery due to a Type A aortic dissection. This case demonstrates the value of ECMO in assisting right heart function to ensure stable hemodynamics and myocardial recovery in the type A aortic dissection with coronary involvement.

Patency of individual and sequential coronary artery bypass in patients with ischemic heart disease: a meta-analysis

Abstract Objective: To evaluate the patency of individual and sequential coronary artery bypass in patients with ischemic heart disease. Methods: We searched PubMed, Cochrane Library, Excerpta Medica Database, and ClinicalTrials.gov databases for controlled trials. Endpoints included graft patency, anastomosis patency, occluded rates in left anterior descending (LAD) system and right coronary artery (RCA) system, in-hospital mortality, and follow-up mortality. Pooled risk ratios (RRs) and standardized mean difference (SMD) were used to assess the relative data. Results: Nine cohorts, including 7100 patients and 1440 grafts under individual or sequential coronary artery bypass. There were no significant differences between individual and sequential coronary artery bypass in the graft patency (RR=0.96; 95% CI=0.91-1.02; P=0.16; I2=87%), anastomosis patency (RR=0.95; 95% CI=0.91-1.00; P=0.05; I2=70%), occluded rate in LAD system (RR=1.03; 95% CI=0.92-1.16; P=0.58; I2=37%), occluded rate in RCA system (RR=1.36; 95% CI=0.72-2.57; P=0.35; I2=95%), in-hospital mortality (RR=1.57; 95% CI=0.92-2.69; P=0.10; I2=0%), and follow-up mortality (RR=0.96; 95% CI=0.36-2.53; P=0.93; I2=0%). Conclusion: No significant differences on clinical data were observed regarding anastomosis patency, occluded rate in LAD system, occluded rate in RCA system, in-hospital mortality, and follow-up mortality, indicating that the patency of individual and the patency of sequential coronary artery bypass are similar to each other.