Influencia del antecedente de intervención coronaria percutánea sobre los desenlaces angiográficos y clínicos en pacientes con infarto agudo de miocardio con elevación del segmento ST / Impact of previous percutaneous coronary intervention on angiographic and clinical outcomes in patients with ST-segment elevation myocardial infarction

Resumen Antecedentes: El pronóstico de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) y antecedente de intervención coronaria percutánea (ICP) es incierto. Objetivos: Evaluar si la ICP previa en pacientes con IAMCEST incrementa el riesgo de eventos cardiovasculares mayores y si el flujo final epicárdico varía según la estrategia de reperfusión. Material y métodos: Subestudio de PHASE-MX, observacional, longitudinal y comparativo, de pacientes con IAMCEST reperfundidos en menos de 12 horas de iniciados los síntomas, divididos conforme el antecedente de ICP. El acaecimiento del criterio de valoración principal (muerte cardiovascular, reinfarto, insuficiencia cardíaca y choque cardiogénico) dentro de los 30 días se comparó con estimaciones de Kaplan-Meier, prueba de rangos logarítmicos y modelo de riesgos proporcionales de Cox. El flujo epicárdico final se evaluó con el sistema de clasificación del flujo TIMI después de la reperfusión. Resultados: Se incluyeron 935 pacientes, 85.6 % del sexo masculino, 6.9 % de los cuales tenía antecedente de ICP; 53 % recibió terapia farmacoinvasiva y 47 %, ICP primaria. La incidencia del criterio de valoración principal en pacientes con ICP previa fue de 9.8 % versus 13.3 % en aquellos sin ese antecedente (p = 0.06); 87.1 % de los pacientes con ICP previa obtuvo flujo final de grado TIMI 3 versus 75 % del grupo con estrategia farmacoinvasiva (p = 0.235). Conclusiones: El antecedente de ICP no incrementa el riesgo de eventos cardiovasculares mayores a los 30 días en pacientes con IAMCEST; sin embargo, impacta negativamente en el flujo sanguíneo angiográfico final de los pacientes que recibieron terapia farmacoinvasiva (en comparación con ICP primaria).

Abstract Background: The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain. Objectives: To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy. Material and methods: Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were divided according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Final epicardial blood flow was assessed using the TIMI grading system after reperfusion. Results: A total of 935 patients were included; 85.6% were males, and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs. 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235). Conclusions: A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI).

Infarto de miocardio en Argentina. Tercer reporte del registro ARGEN-IAM-ST y comportamiento de la mortalidad en 8 años / Acute Myocardial Infarction in Argentina. Third ARGEN-IAM-ST Registry Report and 8-Year Mortality Behavior

RESUMEN Introducción. Se presenta el tercer reporte general del registro continuo de infarto ARGEN- IAM-ST. Objetivos. Evaluar los principales marcadores de atención y las complicaciones del infarto agudo de miocardio (IAM) con elevación del segmento ST en el registro continuo de infarto ARGEN-IAM-ST. Conocer la evolución de la terapia de reperfusión y la mortalidad en los últimos 8 años. Material y métodos. Estudio prospectivo multicéntrico, con alcance nacional. Se incluyeron pacientes con IAM con elevación del segmento ST de hasta 36 horas de evolución. Resultados. Se incluyeron 6765 pacientes, con una edad media de 61 ± 12 años, 65 % de género masculino. Se observó una importante carga de factores de riesgo cardiovascular: hipertensión arterial 58 %, diabetes 23 %, dislipidemia 42 %, tabaquismo activo 37 % y antecedentes familiares de enfermedad cardiovascular 17 %. El 13,5 % presentó antecedente de enfermedad coronaria; al ingreso un 49 % presentó IAM de cara anterior y el 23 % falla cardíaca. La mediana de tiempo de dolor a la consulta fue de 120 minutos (rango intercuartílico, RIC, 60-285), el tiempo puerta-aguja fue de 50 minutos (RIC 25-110) y el tiempo puerta balón fue de 100 minutos (RIC 58-190). La mortalidad general intrahospitalaria fue del 8,8 %. Se realizó un análisis exploratorio y descriptivo para observar la variación de la reperfusión y mortalidad durante 8 años donde no se muestran cambios acentuados en la mortalidad a pesar de las altas tasas de reperfusión. Conclusión. En los últimos 8 años la mortalidad registrada en el registro ARGEN IAM-ST se ha mantenido en valores elevados a pesar de las altas tasas de reporte de reperfusión.

ABSTRACT Background. The continuous Argentine ST-segment Elevation Acute Myocardial Infarction (ARGEN-IAM-ST) registry presents its third general report. Objectives. The aim of this study was to evaluate the main ST-segment elevation myocardial infarction (STEMI) markers of care and its complications in the continuous ARGEN-IAM-ST registry, and assess the outcome of reperfusion therapy and mortality in the last 8 years. Methods. This was a national, prospective, multicenter study, including STEMI patients with up to 36-hour evolution. Results. A total of 6765 patients, mean age 61±12 years, 65 % male , were included in the study. A significant burden of cardiovascular risk factors was observed: 58 % of patients had hypertension, 23 % diabetes, 42 % dyslipidemia, 37 % were active smokers, and 17 % had a family history of cardiovascular disease. In 13.5 % of cases, patients had prior history of coronary heart disease. On admission, 49 % presented with anterior AMI and 23 % with heart failure. Median (interquartile range, IQR) pain-consultation time was 120 minutes (IQR 60-285), door-to-needle time 50 minutes (IQR 25-110) and door-to-balloon time 100 minutes (IQR 58-190) Overall in-hospital mortality was 8.8 %. An exploratory and descriptive analysis was performed to assess the variation in reperfusion and mortality over 8 years, showing no marked changes in mortality despite high reperfusion rates. Conclusion. In the last 8 years, the mortality recorded in the ARGEN-IAM-ST registry has remained at high values despite the high reperfusion rates reported.

Efecto del posacondicionamiento isquémico remoto sobre la fracción de eyección del ventrículo izquierdo en pacientes con infarto de miocardio con elevación del segmento ST sometidos a intervención coronaria percutánea primaria / Effect of remote ischemic postconditioning on left ventricular ejection fraction in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Resumen Antecedentes: En los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST), el acondicionamiento isquémico puede ayudar a limitar la remodelación ventricular. Objetivos: Investigar el efecto del posacondicionamiento isquémico remoto (PAIR) en la función del ventrículo izquierdo durante la intervención coronaria percutánea primaria (ICPP) en pacientes con IAMCEST. Material y métodos: Estudio de intervención pre y posprueba con un total de 60 pacientes con IAMCEST. Los pacientes fueron divididos en dos grupos: con y sin PAIR. Resultados: En el seguimiento de seis meses se observó una diferencia significativa en la fracción de eyección del ventrículo izquierdo en pacientes con ICPP, la cual fue mayor en el grupo con PAIR en comparación con el grupo sin PAIR: 1.0 (−1.0 a 4.3) versus −1.0 (−4.0 a –1.3), p = 0.033. En la medición de seis meses, el volumen sistólico final del ventrículo izquierdo en los pacientes sin PAIR fue mayor en comparación con el grupo homólogo: 79.3 ± 30.5 mL versus 64.4 ± 21.4 mL, p = 0.032. Conclusiones: PAIR muestra efectos favorables en la función ventricular izquierda y, por lo tanto, en el futuro podría ser una estrategia cardioprotectora potencial contra la lesión por isquemia-reperfusión en pacientes con IAMCEST.

Abstract Background: Ischemic conditioning may help patients with ST-segment elevation myocardial infarction (STEMI) to limit ventricular remodeling. Objectives: To investigate the effect of remote ischemic postconditioning (RIPC) on left ventricular function during primary percutaneous coronary intervention (PPCI) in patients with STEMI. Material and methods: Pre- and post-test intervention study with a total of 60 STEMI patients. Patients were divided in two groups: with and without RIPC. Results: At 6-month follow-up evaluation, a significant difference in left ventricular ejection fraction was observed in patients who underwent PPCI, which was higher in the group with RIPC in comparison with the group without RIPC: 1.0 (−1.0 to 4.3) vs. −1.0 (−4.0 to –1.3), p = 0.033. In addition, at 6-month measurement, left ventricular end-systolic volume in patients without RIPC: was higher in comparison with their counterparts: 79.3 ± 30.5 mL versus 64.4 ± 21.4 mL, p = 0.032. Conclusions: RIPC shows favorable effects on left ventricular function and, therefore, in the future, it could be a potential cardioprotective strategy against ischemia-reperfusion injury in STEMI patients.

The Predictive Value of R Wave Peak Time to Detect Thrombus Burden in St-segment Elevation Myocardial Infarction: A Retrospective Cohort Study in a Tertiary Medical Center

Abstract Background: Patients with higher thrombus burden have higher procedural complications and more long-term adverse cardiac events. Detecting patients with high thrombus burden (HTB) before coronary intervention could help avoid procedural complications. Objective: The research aimed to analyze the R wave peak time (RWPT) on the electrocardiogram to predict thrombus burden before coronary angiography in patients with acute ST-segment elevation myocardial infarction (STEMI). Materials and Methods: A total of 159 patients with STEMI were included in the study conducted at a tertiary medical center. The thrombolysis in myocardial infarction (TIMI) thrombus scale was applied to assess the thrombus burden. TIMI thrombus grades 0, 1, 2, and 3 were accepted as low; 4 and 5 had HTB. RWPT was measured from the beginning of the QRS complex to the R-peak from the leads pointing to the infarct-related artery. Results: Patients were divided into two groups according to their angiographically defined thrombus burden as low and high. The low thrombus burden group (LTB) comprised fifty-four patients, whereas the HTB group comprised 105 patients. In the LTB group, RWPT was 47.96 ± 9.17 ms, and in the HTB group was 53.58 ± 8.92 ms; it was significantly longer (p < 0.01). Receiver operating characteristic analysis showed that a cut-off value of preprocedural RWPT of > 46.5 ms predicted the occurrence of HTB with a sensitivity and specificity of 87.62% and 51.85%, respectively (AUC 0.682, 95% CI 0.590-0.774, p < 0.001). Conclusion: The present study evaluated the relationship between the RWPT and thrombus burden in STEMI patients. Based on the results, RWPT is an independent predictor of HTB.

Performance Measures in STEMI after COVID-19 Pandemic: Results from the RECUIMA Registry

Abstract Background To offer proper medical care to patients with ST-segment Elevation Acute Myocardial Infarction (STEMI) in low- and middle-income settings (LMIS) is challenging. However, it is not known if performance indicators have changed back after the epidemiological recovery. Objective to describe performance measures (PM) in patients with STEMI during and after the COVID-19 pandemic. Methods Observational study of patients with STEMI, from an LMIS, with analysis of PM suggested in the 2017 AHA-ACC Performance Measures for Adults with STEMI. COVID-19 period was determined from January 2020 to October 2021, and from November 2021 to February 2022 as the post-COVID-19 period. Baseline characteristics, treatments and selected PM were compared using the χ2 test or Mann-Whitney U test. All tests were two-sided, and statistical significance was considered as p-value <0.05. Coronary interventionism-related PM were not reported. Results Administration of thrombolysis decreased (71.2% vs 51.6% (p: 0.001)), while the delay time for its administration (Median (Interquartile Range)) increased considerably (30 min (16-60) to 45 min (35- 60) (p: 0.003)). Aspirin at admission was administered in each period at 92.9% vs 94.2% (p: 0.62); and at discharge to 97.8% vs 98.9% (p: 0.48). Beta-blockers, P2Y12 inhibitors, statins, and angiotensin-converting enzyme inhibitors in patients with heart failure were administered to 67.1% vs 85.1% (p: 0.01), 96.4% vs 84% (p: 0.001), 96.2 % vs 95.7% (p: 1), and 81.2% vs 94.3% (p: 0.14), respectively. Conclusion Despite this being a current period of epidemiological recovery, the COVID-19 pandemic continues to negatively impact the care of patients with STEMI.

Is there an Electro-Angiographic Correlation in RD Infarction?

Introduction: Coronary angiography is the examination of choice in the evaluation of coronary anatomy during acute myocardial infarction, particularly of the right ventricle (RV), whose diagnosis remains difficult. The electrocardiogram reflects the pathophysiology of myocardial ischemia, thus allowing prediction of the culprit lesion. Objective: To investigate the correlation between electrical and coronary data and to judge the reproducibility of the electrocardiogram in identifying the culprit lesion in RV infarction. Materials and Methods: Retrospective study of patients hospitalized in the Cardiology Department of the Mohammed VI University Hospital in Marrakech over a period of 24 months for MDI extended to the RV. Results: During the study period, 120 patients were hospitalized for MI with RV extension. Inferior MI represented 70% of all cases of infarction extended to the RV. It is represented electrically by isolated ST-segment elevation in V3R found in 76%, as well as in association with an elevation in V4R in 45% of cases. Conduction disorders were noted in 38% of cases, presented essentially by first degree atrioventricular block, without any electrical specificity. Coronary angiography was performed in 91% of patients, half of whom underwent coronary angioplasty. A bi-truncular involvement (RC + VIA) was found in 40% of cases, the middle DC is the culprit lesion in almost half of the cases of VD infarction. The presence of an ST elevation in the isolated V3R shunt is a specific criterion of right middle coronary involvement, found in 48% of patients. Conclusion: The ECG remains an essential tool in the early prediction of the artery responsible for the infarction. Because of its complementary nature, the combination of ECG and coronary angiography is essential for a better evaluation of acute myocardial infarction.

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.

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

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

Relación del supradesnivel del segmento ST en aVR con las complicaciones cardiovasculares / Relationship of ST-segment elevation in AVR to cardiovascular complications

Introducción: El patrón de supradesnivel del segmento ST en aVR en el síndrome coronario agudo se asocia con un aumento de la mortalidad. Objetivo: Evaluar la relación entre el patrón de supradesnivel del segmento ST en aVR y las complicaciones cardiovasculares no letales. Método: Estudio observacional de corte transversal, con componente analítico de todos los pacientes ingresados con síndrome coronario agudo sin elevación del segmento ST, en el Hospital Universitario Manuel Fajardo de la Habana entre los años 2016 y 2020. Resultados: Predominó el sexo femenino en el primer grupo, con una mediana de 78 años. Hubo incidencia de cardiopatía isquémica (75 por ciento y 56,4 por ciento) e hipertensión arterial (78,8 por ciento y 85,8 por ciento ). Se determinó una relación estadística significativa entre el patrón con elevación del segmento ST en aVR y las complicaciones cardiovasculares con un riesgo relativo de 5,769 veces. Conclusiones: El patrón de supradesnivel del segmento ST en un síndrome coronario agudo sin elevación del segmento ST predice complicaciones intrahospitalarias cardiovasculares no letales(AU)

Introduction: The pattern of ST-segment elevation in aVR in acute coronary syndrome is associated with increased mortality. Objective: To evaluate the relationship between the pattern of ST-segment elevation in aVR and nonlethal cardiovascular complications. Methods: Observational cross-sectional study, with analytical component of all patients admitted with non-ST-segment elevation acute coronary syndrome at the Manuel Fajardo University Hospital of Havana between 2016 and 2020. Results: Female gender predominated in the first group, with an average age of 78 years. There was incidence of ischemic heart disease (75 percent and 56.4 percent) and arterial hypertension (78.8 percent and 85.8 percent). A significant statistical relationship was determined between the pattern with ST-segment elevation in aVR and cardiovascular complications with a relative risk of 5.769 times. Conclusions: ST-segment suprathreshold pattern in non-ST-segment elevation acute coronary syndrome predicts non-lethal in-hospital cardiovascular complications(AU)

Relationship of Microvascular Obstruction with Global and Regional Myocardial Function Determined by Cardiac Magnetic Resonance after ST-Segment Elevation Myocardial Infarction / 中国医学科学杂志(英文版)

Objective To investigate the impact of microvascular obstruction (MVO) on the global and regional myocardial function by cardiac magnetic resonance feature-tracking (CMR-FT) in ST-segment-elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention.Methods Consecutive acute STEMI patients who underwent cardiac magnetic resonance imaging 1 - 7 days after successful reperfusion by percutaneous coronary intervention treatment were included in this retrospective study. Based on the presence or absence of MVO on late gadolinium enhancement images, patients were divided into groups with MVO and without MVO. The infarct zone, adjacent zone, and remote zone were determined based on a myocardial 16-segment model. The radial strain (RS), circumferential strain (CS), and longitudinal strain (LS) of the global left ventricle (LV) and the infarct, adjacent, and remote zones were measured by CMR-FT from cine images and compared between patients with and without MVO using independent-samples t-test. Logistic regression analysis was used to assess the association of MVO with the impaired LV function.Results A total of 157 STEMI patients (mean age 56.66 ± 11.38 years) were enrolled. MVO was detected in 37.58% (59/157) of STEMI patients, and the mean size of MVO was 3.00 ±3.76 mL. Compared with patients without MVO (n =98 ), the MVO group had significantly reduced LV global RS (t= -4.30, P < 0.001), global CS (t= 4.99, P < 0.001), and global LS ( t= 3.51, P = 0.001). The RS and CS of the infarct zone in patients with MVO were significantly reduced (t= -3.38, P = 0.001; t= 2.64, P = 0.01; respectively) and the infarct size was significantly larger (t= 8.37, P < 0.001) than that of patients without MVO. The presence of LV MVO [OR= 4.10, 95%CI: 2.05 - 8.19, P<0.001) and its size [OR=1.38, 95%CI: 1.10-1.72, P=0.01], along with the heart rate and LV infarct size were significantly associated with impaired LV global CS in univariable Logistic regression analysis, while only heart rate (OR=1.08, 95%CI: 1.03 - 1.13, P=0.001) and LV infarct size (OR=1.10, 95%CI: 1.03 - 1.16, P=0.003) were independent influencing factors for the impaired LV global CS in multivariable Logistic regression analysis.Conclusion The infarct size was larger in STEMI patients with MVO, and MVO deteriorates the global and regional LV myocardial function.

Short-term prognostic predictive value of deep-learning assisted quantitative myocardial contrast echocardiography in ST-elevated myocardial infarction after primary percutaneous coronary intervention / 中华超声影像学杂志

Objective:To explore the prognostic predictive value of deep neural network (DNN) assisted myocardial contrast echocardiography (MCE) quantitative analysis of ST-elevated myocardial infarction (STEMI) patients after successful percutaneous coronary intervention(PCI).Methods:A retrospective analysis was performed in 97 STEMI patients with thrombolysis in myocardial infarction-3 flow in infarct vessel after primary PCI in Renmin Hospital of Wuhan University from June to November 2021. MCE was performed within 48 h after PCI. Patients were followed up to 120 days. The adverse events were defined as cardiac death, hospitalization for congestive heart failure, reinfarction, stroke and recurrent angina. The framework consisted of the U-net and hierarchical convolutional LSTMs. The plateau myocardial contrast intensity (A), micro-bubble rate constant (β), and microvascular blood flow (MBF) for all myocardial segments were obtained by the framework, and then underwent variability analysis. Patients were divided into low MBF group and high MBF group based on MBF values, the baseline characteristics and adverse events were compared between the two groups. Other variables included biomarkers, ventricular wall motion analysis, MCE qualitative analysis, and left ventricular ejection fraction. The relationship between various variables and prognosis was investigated using Cox regression analysis. The ROC curve was plotted to evaluate the diagnostic efficacy of the models, and the diagnostic efficacy of the models was compared using the integrated discrimination improvement index (IDI).Results:The time-cost for processing all 3 810 frames from 97 patients was 377 s. 92.89% and 7.11% of the frames were evaluated by an experienced echocardiographer as "good segmentation" and "correction needed". The correlation coefficients of A, β, and MBF ranged from 0.97 to 0.99 for intra-observer and inter-observer variability. During follow-up, 20 patients met the adverse events. Multivariate Cox regression analysis showed that for each increase of 1 IU/s in MBF of the infarct-related artery territory, the risk of adverse events decreased by 6% ( HR 0.94, 95% CI =0.91-0.98). There was a 4.5-fold increased risk of adverse events in the low MBF group ( HR 5.50, 95% CI=1.55-19.49). After incorporating DNN-assisted MCE quantitative analysis into qualitative analysis, the IDI for prognostic prediction was 15% (AUC 0.86, sensitivity 0.78, specificity 0.73). Conclusions:MBF of the area supplied by infarct-related artery after STEMI-PCI is an independent protective factor for short-term prognosis. The DNN-assisted MCE quantitative analysis is an objective, efficient, and reproducible method to evaluate microvascular perfusion. Assessment of culprit-MBF after PCI in STEMI patients adds independent short-term prognostic information over qualitative analysis.It has the potential to be a valuable tool for risk stratification and clinical follow-up.

The application of scenario simulation teaching in acute ST-segment elevation myocardial infarction course for the training of "5+3" professional master / 中华医学教育探索杂志

Objective:To explore the application and effect of scenario simulation teaching in ST-segment elevation myocardial infarction (STEMI) course for emergency training of "5+3" professional master.Methods:A randomized controlled trial was conducted among 48 "5+3" professional masters who would rotate in the emergency department, to compare the test results of the total and three scenes between scenario simulation teaching group ( n=24) and traditional teaching group ( n=24). The STEMI teaching was carried out through simulating the emergency room, standardized patients and first-aid simulators in the simulation teaching group, and the traditional teaching group was taught by conventional classroom teaching. After the class, "Theoretical Examination" and "Questionnaire Survey" were used to evaluate the teaching effect. The former was further divided into "first diagnosis and differential diagnosis of chest pain", "fast identification and processing of STEMI" and "rescue of cardiac arrest" for inter-group and intra-group evaluation. SPSS 20.0 was used to conduct t-test. Results:In the theoretical examination, the scenario simulation teaching group was superior to the traditional teaching group in the test of emergency processing for STEMI course [(82.38±2.41) vs . (68.00±1.95), t=4.64, P<0.001]. In the sub-analysis of scenario simulation teaching group, students in the role-play group had significantly higher scores than others in the non-role-play group [(90.50±3.04) vs . (79.67±2.79), t=2.09, P=0.049]. Scenario simulation teaching group was also superior to traditional teaching group in the "Questionnaire Survey". Conclusion:In the training and teaching of STEMI emergency processing, scenario simulation teaching group proves to be superior to traditional teaching, which deserves further promotion.

Lipoprotein-associated phospholipase A2 combined with D-dimer to fibrinogen ratio to construct a prognostic nomogram model for patients with acute myocardial infarction after percutaneous coronary intervention / 中国医师进修杂志

Objective:To construct acute ST-segment elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI) by using lipoprotein-associated phospholipase A2 (Lp-PLA2) and D-dimer to fibrinogen ratio (D/F) and other indicators postoperative patient prognosis nomogram model and evaluation of its predictive value.Methods:A total of 291 acute STEMI patients admitted to the BenQ Hospital Affiliated to Nanjing Medical University from January 2017 to January 2020 were retrospectively selected, including but not limited to Lp-PLA2 and D/F, were collected. Receiver operating characteristic (ROC) curve and multivariate Logistic regression were used to analyze the risk factors of death within 90 d after PCI in STEMI patients, and Kaplan-Meier survival curves were drawn to compare the survival of patients in different Lp-PLA2 and D/F groups. The R language software was used to build nomogram model and decision curve.Results:The AUCs of LpPLA2 and D/F for predicting the risk of death from cardiac causes at 90 s after PCI in patients with acute STEMI were 0.896 (95% CI 0.850 to 0.932) and 0.884 (95% CI 0.837 to 0.922), respectively. The values were 59.50 μg/L and 0.46 respectively ( P<0.05); the mortality rates of acute STEMI patients in LpPLA2>59.50 μg/L and D/F>0.46 groups after PCI were higher than those in LpPLA2≤59.50 μg/L group and D/F≤0.46 group ( P<0.05); age (>66 years), left ventricular ejection fraction (LVEF) (≤45%), LpPLA2 (>59.50 μg/L), D/F (>0.46), N-terminal brain natriuretic peptide precursor (>1.55 μg/L) and fasting blood glucose (>7.00 mmol/L) were the risk of death from cardiac causes at 90 d after PCI in patients with acute STEMI ( P<0.05); when the risk thresholds were >0.24, the nomogram model could provide significant additional net clinical benefit. Conclusions:Lp-PLA2 and D/F are closely related to the prognosis of patients with acute STEMI after PCI, and the nomogram model constructed in combination with other clinical indicators can effectively predict the risk of death within 90 d after PCI.

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis

Background: Primary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST. Methods: A sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed. Results: Male patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%. Conclusion: In-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI

Usefulness of Immature Granulocytes as A Prognostic Factor in ST-Elevation Myocardial Infarction

ABSTRACT Objective: ST-segment elevation myocardial infarction (STEMI) is a serious, life-threatening disease. Inflammatory markers have recently become the focus of attention in the assessment of severity in the early stages of STEMI. This study aimed to evaluate the importance of immature granulocytes (IG) as a prognostic marker in STEMI. Methods: Patients admitted to the coronary care unit with a diagnosis of STEMI and who underwent primary percutaneous coronary intervention (pPCI) within the period from January 1, 2019 to January 1, 2020, were retrospectively scanned. A total of 146 patients were analised; of these, 112 (76.7%) were male and 34 (33.3) were female, with a mean age of 62.65±14.06 years. Patients' age, gender, haemogram, biochemistry, and mortality results were recorded. The patients were divided into two groups as low (<0.6) and high (≥0.6) IG levels and compared. Results: The mean IG levels were significantly higher in the non-survivor group compared to the survivor group (1.12±0.22 vs. 0.50±0.28, P<0.001). Mortality rates were significantly higher in the high IG group compared to the low IG group (26.9% vs. 9.6%, P=0.006). IG was shown to predict mortality with a sensitivity of 72.2% and a specificity of 77.8% at a cut-off value of 0.65 (area under the curve: 0.740, 95% CI: 0.635-0.846, P<0.001). Conclusion: High IG values in the blood collected at the time of admission to the emergency department are a marker of mortality in patients with STEMI.

A study to compare fibrinolytic therapy versus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction in a tertiary care hospital

Background: ST-segment elevation myocardial infarction (STEMI) is the most dramatic manifestation of coronary artery disease, acute STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic ST elevation and subsequent release of biomarkers of myocardial necrosis. Reperfusion with thrombolysis or PCI (percutaneous coronary intervention) is the current standard of care for STEMI. Aims and Objectives: The aim of the study was to compare the effectiveness of fibrinolytic therapy and primary PCI which are the available reperfusion strategies for STEMI. Materials and Methods: This prospective and observational study was conducted at a tertiary care hospital in Bangalore. Patients presenting with STEMI to emergency department were treated with either fibrinolysis or PCI as per protocol. Patients in each arm were followed up to know the differences in outcome at discharge and 30-day follow-up. Results: Patients admitted with STEMI had overall in hospital mortality of 17 (7.1%) patients, of which 9 (7.6%) patients were from fibrinolysis group and 8 (6.6%) patients from PCI group with no statistically significant difference (P = 0.760). There was significant incidence (P = 0.001) of reinfarct in fibrinolysis group (9.3%) when compared to PCI group (0%). Conclusion: There was no statistically significant mortality difference at discharge and at 30 day between fibrinolysis and primary PCI in patients with STEMI in our study, this may be attributed to use of rescue PCI in failed fibrinolysis patients and early tricuspid valve repair in many patients after fibrinolysis.

Tiempos de reperfusión de un programa guiado por telemedicina para la atención del infarto agudo de miocardio con elevación del ST en la Provincia de La Pampa / Reperfusion Times in a Telemedicine-guided Program for the Management of ST-segment Elevation Myocardial Infarction in the Province of La Pampa

RESUMEN Introducción: Los tiempos de atención médica son un factor relevante para la mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Objetivos: Evaluar los tiempos de reperfusión en pacientes con IAMCEST participantes de un programa de atención médica cardiológica basada en telemedicina en la provincia de La Pampa durante el período transcurrido entre agosto de 2018 y diciembre de 2021. Material y Métodos: Este programa consiste en la protocolización de la atención de los pacientes que cursan un síndrome coronario agudo (SCA) en las diferentes localidades de la provincia, con asistencia cardiológica remota las 24 horas del día, que incluye tanto la asistencia diagnóstica como la coordinación de las medidas terapéuticas, incluyendo la posibilidad de administrar trombolíticos a nivel local, con asistencia remota. Resultados: De un total de 72 IAMCEST evaluados, 44 recibieron como terapia de reperfusión trombolisis, 25 angioplastia primaria, y 3 trombolisis seguida de angioplastia de rescate. De los 47 sujetos que recibieron trombolisis, sólo 5 requirieron de traslado al centro de referencia para realizar este procedimiento. La mediana de tiempo puerta-aguja fue de 24 minutos y el tiempo puerta-balón fue de 105 minutos. El 28% de los sujetos con angioplastia primaria tuvieron un tiempo puerta-balón inferior a los 90 minutos y el 53,2% de los tratados con trombolíticos cumplieron con un tiempo puerta-aguja menor a 30 minutos. Conclusiones: La implementación de un programa de atención descentralizada guiada por telemedicina se asoció a un elevado porcentaje de cumplimento de las metas de implementación de la terapia de reperfusión basada en fibrinolíticos.

ABSTRACT Background: Timing of medical care is a relevant factor for ST-segment elevation myocardial infarction (STEMI) mortality. Objectives: The aim of the present study is to evaluate reperfusion times in STEMI patients participating in a telemedicinebased cardiology care program in the province of La Pampa during the period between August 2018 and December 2021. Methods: This program consists of a protocol for the management of patients with acute coronary syndrome (ACS) in the different locations of the province, with 24-hour remote assistance provided by cardiologists including both diagnostic support and coordination of on-site thrombolysis. Results: Of a total of 72 STEMI patients evaluated, 44 received thrombolysis as reperfusion therapy, 25 received primary percutaneous coronary intervention, and 3 received thrombolysis followed by rescue percutaneous coronary intervention. Of the 47 subjects who received thrombolysis, only 5 required to be transferred to the referral center for this procedure. Median door-to-needle time was 24 minutes and door-to balloon-time was 105 minutes. Twenty-five percent of the subjects had a door-to-balloon time <90 minutes and 53.2% fulfilled a door-to-needle time <30 minutes. Conclusions: The implementation of a telemedicine-guided program for decentralized management of STEMI patients was associated with a high percentage of compliance with the goals of implementing fibrinolytic-based reperfusion therapy.

A Case Report of Successful Fibrinolysis in a Multiple Coronary Ectasia ST-segment Elevation Myocardial Infarction Validated by Coronary Angiography

Coronary artery ectasia (CAE) often presents in the form of an acute coronary syndrome (ACS) caused by slow blood flow leading to thrombus formation in ectatic coronary arteries. The usual approach is thrombectomy with intracoronary thrombolysis but often does not guarantee immediate blood flow. A 45-year-old male presented with anginal chest pain and was diagnosed with ST-segment elevation myocardial infarction (STEMI), managed Immediately with tissue plasminogen activator(t-PA) followed later with coronary angiography revealing diffused Multiple coronary ectasia MCEA with no identified culprit lesions afterward. The patient was followed up periodically, with favorable outcomes on daily aspirin, direct oral anticoagulant (DOAC), and guideline-directed medical therapy (GDMT) for coronary artery disease (CAD) and reduced ejection fraction heart failure (HF-rEF). This case management strategy was dictated by available resources at the time of presentation; however, it signifies the importance and favorable outcome of thrombolysis in CEA/STEMI patients. Future large-scale studies are required toward defining the duration as well as the choice of long-term anticoagulation.

Exosomal miR-152-5p and miR-3681-5p function as potential biomarkers for ST-segment elevation myocardial infarction

Abstract Background: The strain parameters of Real-Time Three-Dimensional Spot Tracking Echocardiography (RT3D-STE) are GLS, GAS, GRS, and GCS, while each index can significantly diagnose Acute Myocardial Infarction (AMI) patients, but none of them can distinguish between NSTEMI and STEMI. MicroRNAs (miRNAs) play essential roles in Acute Myocardial Infarction (AMI), but little is known about the value of exosome miRNA combined with RealTime Three-Dimensional Spot Tracking Echocardiography (RT3D-STE) between ST-segment Elevation Myocardial Infarction (STEMI) and Non-ST-segment Elevation Myocardial Infarction (NSTEMI). Aim: To estimate the exosomal miRNAs related to strain parameters of RT3D-STE as biomarkers for early detection of STEMI and NSTEMI. Methods: The present study collected plasma samples from thirty-four (34) patients with AMI (including STEMI and NSTEMI) and employed high-throughput sequence technology and real-time quantitative polymerase chain reaction (RT-qPCR) to identify the differentially expressed miRNAs. The Pearson correlation coefficient is used to measure the strength of a linear association between differentially expressed miRNAs and strain parameters of RT3D-STE. Results: Twenty-eight (28) differentially expressed exosomal miRNAs were universally identified between STEMI, NSTEM, and normal groups. Among them, there are 10 miRNAs (miR-152-5p, miR-3681-5p, miR-193a-5p, miR-193b-5p miR-345-5p, miR-125a-5p, miR-365a-3p, miR-4520-2-3p, hsa-miR-193b-3p and hsa-miR-5579-5p) with a Pearson correlation greater than 0.6 with RT3D-STE strain parameters. Especially, miR-152-5p and miR-3681-5p showed the most significant correlation with RT3D-STE strain parameters. Target genes of these 10 miRNAs are analyzed for Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways enrichment, and they were found to be mainly involved in the cellular metabolism processes and HIF-1 signaling pathway. RT-qPCR verified the significant differential expression of miR-152-5p and miR-3681-5p between STEMI and NSTEM groups. Conclusion: RT3D-STE and exosome miRNAs can be used as a hierarchical diagnostic system in AMI. If the RT3D-STE is abnormal, the exosome miRNAs can be detected again to obtain more detailed and accurate diagnostic results between STEMI and NSTEM groups. Exosomal miR-152-5p and miR-3681-5p may serve as potential biomarkers for ST-segment elevation myocardial infarction. HIGHLIGHTS RT3D-STE and exosome miRNAs can be used as a hierarchical diagnostic system in AMI. Exosomal miR-152-5p and miR-3681-5p function as potential biomarkers for ST-segment elevation myocardial infarction.

The LDL/HDL ratio predicts long-term risk of coronary revascularization in ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention: a cohort study

Clinical indicators do not adequately predict the long-term prognosis of patients with ST-segment elevation myocardial infarction (STEMI) following percutaneous coronary intervention (PCI). The low-density lipoprotein (LDL)/high-density lipoprotein (HDL) ratio is expected to be a reliable predictor of the long-term prognosis of these patients. This study aimed to explore the correlation between the LDL/HDL ratio and long-term prognosis in STEMI patients undergoing PCI. Patients with confirmed STEMI who underwent PCI in 7 hospitals in China from January 2009 to December 2011 were enrolled. Information about clinical endpoints, including all-cause death and major adverse cardiovascular events, was collected. Overall, 915 patients were included for analysis, the average follow-up time was 112.2 months. According to the LDL/HDL ratio, the patients were divided into 3 groups using the three-quantile method: low (LDL/HDL≤1.963), medium (1.963<LDL/HDL<2.595), and high (LDL/HDL≥2.595) LDL/HDL groups. The rate of coronary revascularization was higher in the high LDL/HDL group (28.52%) than in the low (17.38%, P=0.001) and medium (19.34%, P=0.010) LDL/HDL groups. The hazard ratio of coronary revascularization was significantly higher in the high LDL/HDL group than in the low (P=0.007) and medium (P=0.004) LDL/HDL groups. Increased LDL/HDL ratio was an independent risk factor for long-term coronary revascularization in STEMI patients undergoing PCI (HR=1.231, 95%CI: 1.023-1.482, P=0.028). These findings suggest that an increased LDL/HDL ratio was an independent risk factor for long-term coronary revascularization in STEMI patients undergoing PCI. The risk of coronary revascularization was significantly increased in patients with LDL/HDL≥2.595.