Clinical relevance of angiographic coronary collaterals during primary coronary intervention for acute ST-elevation myocardial infarction / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Collaterals to occluded infarct-related coronary arteries (IRA) have been observed after the onset of acute ST-elevation myocardial infarction (STEMI). We sought to investigate the impact of early coronary collateralization, as evidenced by angiography, on myocardial reperfusion and outcomes after primary percutaneous coronary intervention (PCI).</p><p><b>METHODS</b>Acute procedural results, ST-segment resolution (STR), enzymatic infarct size, echocardiographic left ventricular function, and major adverse cardiac events (MACE) at 6-month follow-up were assessed in 389 patients with STEMI undergoing primary PCI for occluded IRA (TIMI flow grade 0 or 1) within 12 hours of symptom-onset. Angiographic coronary collateralization to the occluded IRA at first contrast injection was graded according to the Rentrop scoring system.</p><p><b>RESULTS</b>Low (Rentrop score of 0 or 1) and high (Rentrop score of 2 or 3) coronary collateralization was detected in 329 and 60 patients, respectively. Patients with high collateralization more commonly had prior stable angina and right coronary artery occlusion, but less often had left anterior descending artery occlusion. At baseline, these patients presented with less extent of ST-segment elevation and lower serum levels of creatine kinase myocardial band (CK-MB) and cardiac troponin I (cTnI). Procedural success rate, STR, corrected TIMI flame count, and area under the curve of CK-MB and cTnI measurements after the procedure were similar between patients with high collateralization and those with low collateralization (for all comparisons P > 0.05). There were no differences in left ventricular ejection fraction and rates of MACE at 6 months according to baseline angiographic collaterals to occluded IRA.</p><p><b>CONCLUSIONS</b>In patients with acute STEMI undergoing primary PCI within 12 hours of symptom-onset, coronary collateralization to the occluded IRA was influenced by clinical and angiographic features. Early recruitment of collaterals limits infarct size at baseline, but has no significant impact on myocardial reperfusion after the procedure and subsequent left ventricular function and clinical outcomes.</p>

The influence of diabetes on left ventricular remodeling after primary percutaneous coronary intervention for patients with acute myocardial infarction / 中国介入心脏病学杂志

Objective To investigate the influence of diabetes mellitus (DM) on left ventricular(LV) remodeling in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Methods Four hundred and fifty-one consecutive patients with acute STEMI treated by primary PCI were prospectively enrolled in the current study. Baseline, angiographic and PCI features and prevalence of LV remodeling at one-week during hospitalization and 6-month clinical follow-up by two-dimensional echocardiography were compared between 93 diabetic and 358 non-diabetic patients. Results Despite similar baseline clinical and angiographic characteristics, symptom-to-door time was longer (399±106 min vs. 321±116 min, P=0.006) and prevalence of multivessel disease was higher (65.6%vs. 51.7%, P=0.02) in diabetic patients. More patients in diabetic group had LV remodeling at 6-month clinical follow-up (29.0%vs. 17.3%, P=0.01), and DM was an independent predictor of LV remodeling (RR 2.1, 95%CI 1.31-4.79, P=0.02). The rate of rehospitalization due to heart failure did not differ between diabetic and non-diabetic patients (12.9%vs. 8.1%, P=0.15), however, more adverse events occurred in patients with LV remodeling comparing to those without LV remodeling (25.8% vs. 6.6%, P < 0.001). Conclusions Diabetic patients with STEMI often have an increased risk of LV remodeling after treated by primary PCI. Thus, comprehensive therapeutic strategy for diabetic patients presented with STEMI is required considering the poor prognosis of these patients with LV remodeling.

Efficacy and safety of intra-coronary bolus injection of tirofiban during primary percutaneous coronary intervention for patients with acute ST-segment elevation myocardial infarction / 中国介入心脏病学杂志

Objective To analyse and compare the effects and safety of early use (in emergency room, intravenous loading followed by infusion) with bolus injection during primary PCI of tirofiban, on post-procedural TIMI flow and 30d clinical outcomes. Methods Seven hundred and seven patients with acute STEMI treated by primary PCI in Ruijin hospital were retrospectively and enrolled screened. Among them, 86 patients with single bolus intra-coronary injection of tirofiban (25 μg/kg) during the procedure were served as observation group. Baseline, angiographic, PCI features and rate of major adverse cardiac events (MACE) at 30 d follow-up were compared with those received early intravenous infusion of tirofiban (10ug/kg bolus followed by 0.15μg/(kg·min) intravenous infusion)(control group, n=239). Results Compared with control group, patients in observation group were older[(63.8±11.4) vs. (57.9±8.8), P=0.01], had higher prevalence of hypertension (58.6%vs. 51.0%, P=0.005), multivessel disease (57.0%vs. 34.3%, P<0.001), and female in gender (40.7%vs. 25.1%, P=0.006). Post-procedural TIMI flow in culprit vessel and TMP grade were comparable between the two groups (P=0.66 and P=0.48, respectively). Reduction in TIMI minimal bleeding events were found in the observation group (2.3%vs. 9.6%, P=0.03). MACE free survival rate at 30d clinical follow-up was similar between the two groups (P=0.48). Conclusions Single bolus intra-coronary injection of tirofiban exerts similar effects in post-procedural TIMI flow, TMP grade in culprit vessel and 30d clinical outcomes compared with early use in emergency room with intra-venous loading and infusion, nevertheless, intra-coronary injection resulted in significantly reduced TIMI minimal bleeding events. Prospective, randomized clinical study is mandatory to prove our current results.

Association of insulin resistance with spontaneous recanalization of infarct-related arteries in patients with a-cute myocardial infarction / 中国综合临床

Objective To clarify the role of insulin resistance on spontaneous recanalization of infarct-relat-ed arteries in the early phase of acute ST-elevation myocardial infarction (STEMI) in patients with normal glucose tolerance. Methods 141 consecutive patients with normal glucose tolerance and acute STEMI were enrolled in our study. Subjects were divided into TIMI 0-1 group (n =91 ) and TIMI 2-3 group (n =50) by primary coronary angi-ngraphy (CAG). The Gemini score and 0-3-vessel disease score estimated the severity and extent of coronary artery disease (CAD). Metabolic parameters and homeostasis model assessment for insulin resistance (IRI) were deter-mined. Results Serum level of fasting insulin, IRI and Gemini score were higher in TIMI 0-1 group than in TIMI 2-3 group [ (11.52±6.22)mU/L vs (7.54±3.65)mU/l,(2.79±2.32) vs (1.73±1.26),(59.17±26.95) vs ( 38.46±22.74) ( P <0.01)]. IRI was positively associated with Gemini score (r=0.185,P <0.05 ). Multivariate Logistic regression analysis revealed that IRI was independent risk factor influencing spontaneous recanalization of in-farct-related urteries(OR=2.87,95% CI=1.09-7.57,P<0.05). Conclusion Insulin resistance is independent risk factor influencing spontaneous recanalizafion of infarct-related arteries in the early phase of acute STEMI in pa-tients with normal glucose tolerance.

The relationship of the gene polymorphisms of matrix metalloproteinase-1, -2, -3 and -9 to the progression of coronary atherosclerotic plaque / 介入放射学杂志

Objective To evaluate the influence of the gene polymorphisms of matrix metalloproteinase(mmp)-1 ,-2,-3 and -9 on coronary atherosclerotic plaque progression. Methods During the period of January 2005-December 2008, 80 patients with coronary heart disease underwent two times coronary angiography at authors' hospital. Based on the angiographic findings, the patients were classified into plaque progression group (n = 31 ) and plaque non-progression group (n = 49). Coronary atheroselerotic plaque progression was arbitrarily defined as that the minimal lumen diameter (MLD) of coronary artery showed a decrease ≥ 0.4 mm on the second coronary angiography. The detailed history and clinical examination results were collected, including serum concentrations of lipid profiling, fasting glucose and hs-CRP. Genotypings for polymorphic variances of MMP-1 (-1607 G/GG), MMP-2 (-955 A/C), MMP-3 (-1612 5A/6A ) and MMP-9 (-1562 C/T) were performed by polymerase chain reaction (PCR) and sequencing analysis in two groups.Comparison of the clinical characteristics and polymorphisms between two groups was made to assess their effects on coronary atherosclerotic plaque progression. Results More female patients and patients with acute coronary syndrome (ACS) were noted in patients with plaque progression compare to those with no progression (41.9% vs. 18.4%, P < 0.05 and 77.4% vs. 46.3%, P < 0.01, respectively).The serum hs-CRP level also significantly increased in group with plaque progression (0.26 ± 0.44 mg/L vs.0.02 ± 0.14 mg/L, P < 0.01). Multivariable logistic regression analysis revealed that serum hs-CRP concentration and ACS were independent risk factors of coronary atherosclerotic plaque progression (OR:12.63,95% CI:1.45-110.29, P < 0.05 and OR:2.99,95% CI:1.04-8.63, P < 0.05, respectively). The frequencies of 6A/6A genotype and 6A allele of MMP-3 promoter at location -1612 were significantly higher in group with plaque progression than that in group with no progression (87.1% vs. 53.1%, P < 0.01 and 93.5% vs. 75.5%, P < 0.01, respectively). However, no significant differences in the distribution of MMP-1,-2 and -9 polymorphisms existed between two groups. Conclusion ACS, feminine gender, high serum hs-CRP concentration and 5A/6A polymorphism in the MMP-3 gene promoter are closely associated with coronary atherosclerotic plaque progression. In addition, 5A/6A polymorphism of MMP-3 can be used as a marker for plaque progression.