Microvascular perfusion and cardiac function after revascularization assessed by myocardial contrast echocardiography in patients with acute ST-segment elevation myocardial infarction / 中华心血管病杂志

Objectives: To evaluate microvascular perfusion and left ventricular function in patients with acute ST-segment elevation myocardial infarction after revascularization using myocardial contrast echocardiography (MCE), and to explore clinical influencing factors of abnormal microvascular perfusion in these patients. Methods: This is a cross-sectional study. The analysis was performed among patients admitted to Peking University People's Hospital for acute ST-segment elevation myocardial infarction (STEMI) from June 2018 to July 2021. All patients underwent percutaneous coronary intervention (PCI) and completed MCE within 48 hours after PCI. Patients were divided into normal myocardial perfusion group and abnormal perfusion group according to the myocardial perfusion score. The echocardiographic indexes within 48 hours after PCI, including peak mitral valve flow velocity (E), mean value of early diastolic velocity of left ventricular septum and lateral mitral annulus (Em), left ventricular global longitudinal strain (GLS) and so on, were analyzed and compared between the two groups. Multivariate logistic regression analysis was used to evaluate the influencing factors of myocardial perfusion abnormalities. Results: A total of 123 STEMI patients, aged 59±13 years with 93 (75.6%) males, were enrolled. There were 50 cases in the normal myocardial perfusion group, and 73 cases in the abnormal myocardial perfusion group. The incidence of abnormal myocardial perfusion was 59.3% (73/123). The left ventricular volume index ((62.3±18.4)ml/m2 vs. (55.1±15.2)ml/m2, P=0.018), wall motion score index (WMSI) (1.59 (1.44, 2.00) vs. 1.24(1.00, 1.47), P<0.001) and mitral E/Em (17.8(12.0, 24.3) vs. 12.2(9.2, 15.7), P<0.001) were significantly higher whereas left ventricular global longitudinal strain (GLS) ((-10.8±3.4)% vs. (-13.8±3.5)%, P<0.001) was significantly lower in the abnormal myocardial perfusion group than those in the normal myocardial perfusion group. Multivariate logistic regression analysis showed that left anterior descending (LAD) as culprit vessel (OR=3.733, 95%CI 1.282-10.873, P=0.016), intraoperative no/low-reflow (OR=6.125, 95%CI 1.299-28.872, P=0.022), and peak troponin I (TnI) (OR=1.018, 95%CI 1.008-1.029, P=0.001) were independent risk factors of abnormal myocardial perfusion. As for ultrasonic indexes, deceleration time of mitral E wave (OR=0.979, 95%CI 0.965-0.993, P=0.003), mitral E/Em (OR=1.100, 95%CI 1.014-1.194, P=0.022) and WMSI (OR=7.470, 95%CI 2.630-21.222, P<0.001) were independently related to abnormal myocardial perfusion. Conclusions: The incidence of abnormal myocardial perfusion after PCI is high in patients with acute STEMI. Abnormal myocardial perfusion is related to worse left ventricular systolic and diastolic function. LAD as culprit vessel, intraoperative no/low-reflow and peak TnI are independent risk factors of abnormal myocardial perfusion.

Comparação entre Dois Escores de Risco quanto à Predição de Obstrução Microvascular Coronariana durante a Intervenção Percutânea Primária / The Comparison between Two Risk Scores as for the Prediction of Coronary Microvascular Obstruction during Primary Percutaneous Intervention

Resumo Fundamento: Para pacientes com infarto do miocárdio com elevação do segmento ST (IAMCST) que sofrem de obstrução coronariana microvascular funcional e estrutural (OCM) subsequente, nenhuma abordagem terapêutica específica e definitiva de atenuação foi comprovada como válida em testes de larga escala atuais, o que destaca a necessidade de abordar seu reconhecimento precoce. Objetivos: Este estudo teve como objetivo comparar o desempenho de dois escores de risco clínico com uma medida objetiva de OCM durante intervenção coronária percutânea (ICP) em casos de IAMCST Métodos: A medição do índice de resistência microcirculatória (IRM) foi realizada e os parâmetros clínicos e angiográficos basais também foram registrados. Os pacientes foram divididos em entre os grupos OM (obstrução microvascular) e NOM (não-obstrução microvascular), de acordo com o valor de IRM pós-procedimento. O risco de OCM foi avaliado para todos os participantes pelos escores preditivos SAK e ATI, respectivamente. Cada sistema foi calculado somando-se as pontuações de todas as variáveis. As curvas de características do operador receptor (ROC) e a área sob a curva (AUC) de dois modelos de risco foram utilizadas para avaliar o desempenho discriminatório. Um ecocardiograma foi realizado sete dias após o procedimento para avaliar a fração de ejeção do ventrículo esquerdo (FEVE). Um valor P bicaudal de <0,05 foi considerado estatisticamente significativo. Resultados: Entre os 65 pacientes elegíveis com IAMCST, 48 foram alocados no grupo NOM e 17 no grupo OM, com uma incidência de OCM de 26,15%. Não houve diferença significativa na AUC entre os dois escores. A FEVE avaliada para o grupo NOM foi maior do que para o grupo OM. Conclusão: Os escores SAK e ATI tiveram bom desempenho para estimar o risco de OCM após ICP primário para pacientes com IAMCST.

Abstract Background: For patients with ST-segment elevation myocardial infarction (STEMI) that are suffering from subsequent coronary microvascular functional and structural obstruction (CMVO), no specific and definitive therapeutic approaches of attenuation have been proven valid in up-to-date large-scale tests, which highlights the urge to address its early recognition. Objectives: This study aimed to compare the performance of two clinical risk scores with an objective measurement of CMVO during percutaneous coronary intervention (PCI) with STEMI. Methods: The Index of Microcirculatory Resistance (IMR) measurement was conducted and the baseline clinical and angiographic parameters were also recorded. The patients were divided into MO (Microvascular obstruction) or NMO (Non-microvascular obstruction) groups according to the post-procedure IMR value. The CMVO risk was evaluated for all participants by SAK and ATI predictive scores, respectively. Each system was calculated by summing the scores of all variables. The receiver operator characteristic (ROC) curves and the area under the curve (AUC) of two risk models were used to evaluate the discriminatory performance. An echocardiography was performed seven days after the procedure to evaluate left ventricular ejection fraction (LVEF). A two-sided P-value of <0.05 was considered statistically significant. Results: Among the 65 eligible STEMI patients, 48 patients were allocated in the NMO group and 17 in the MO group, with a CMVO incidence of 26.15%. There was no significant difference in the AUC between both scores. The LVEF evaluated for the NMO group was higher than that of MO group. Conclusion: Both SAK and ATI scores performed well in estimating CMVO risk after primary PCI for STEMI patients.

O Escore Gensini e a Carga Trombótica Adicionam Valor Preditivo ao Escore SYNTAX na Detecção de No-Reflow após Infarto do Miocárdio / Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction

Resumo Fundamento O fenômeno de no-reflow após a intervenção coronária percutânea está associado a um pior prognóstico em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). O escore SYNTAX é um bom preditor de no-reflow. Objetivo Nosso objetivo foi avaliar se a carga aterosclerótica (escore Gensini) e a carga trombótica na artéria coronária culpada melhorariam a capacidade do escore SYNTAX para detectar o no-reflow. Métodos Neste estudo coorte prospectivo, foram estudados pacientes com IAMCSST consecutivos que se apresentaram dentro de 12 horas a partir do início dos sintomas. O no-reflow foi definido como fluxo TIMI < 3 ou fluxo TIMI =3 mas grau de blush miocárdico (myocardial blush grade) < 2. A carga trombótica foi quantificada de acordo com o grau TIMI de trombo (0 a 5). Resultados Foram incluídos 481 pacientes no estudo, com idade média de 61±11 anos. O fenômeno de no-reflow ocorreu em 32,8% dos pacientes. O escore SYNTAX (OR=1,05, IC95% 1,01-1,08, p<0,01), a carga trombótica (OR=1,17, IC95% 1,06-1,31, p<0,01), e o escore Gensini (OR=1,37, IC95% 1,13-1,65, p<0,01) foram preditores independentes do no-reflow. Os escores combinados apresentaram uma maior área sob a curva quando comparados ao escore SYNTAX isolado (0,78 [0,73-0,82] vs 0,73 [0,68-0,78], p=0,03). A análise da melhora da reclassificação líquida (NRI) categórica (0,11 [0,01-0,22], p=0,02) e contínua (NRI>0) (0,54 [0,035-0,73], p<0.001) mostrou melhora na capacidade preditiva do no-reflow no modelo combinado, com melhora da discriminação integrada (IDI) de 0,07 (0,04-0,09, p<0,001). Conclusões Nossos achados sugerem que, em pacientes com IAMCSST submetidos à intervenção coronária percutânea, a carga aterosclerótica e a carga trombótica na artéria culpada adicionam valor preditivo ao escore SYNTAX na detecção do fenômeno no-reflow. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background No-reflow after percutaneous coronary intervention is associated with poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). SYNTAX score is a good predictor of no-reflow. Objective We aimed to evaluate whether atherosclerotic burden (Gensini score) and thrombus burden in the culprit coronary artery would improve the ability of the SYNTAX score to detect no-reflow. Methods In this prospective cohort study, consecutive patients with STEMI who presented within 12 h of onset of symptoms were selected for this study. No-reflow was defined as TIMI flow < 3 o r TIMI flow = 3 but myocardial blush grade <2. Thrombus burden was quantified according to the TIMI thrombus grade scale (0 to 5). Results A total of 481 patients were included (mean age 61±11 years). No-reflow occurred in 32.8%. SYNTAX score (OR=1.05, 95%CI 1.01-1.08, p<0.01), thrombus burden (OR=1.17, 95%CI 1.06-1.31, p<0.01), and Gensini score (OR=1.37, 95%CI 1.13-1.65, p<0.01) were independent predictors of no-reflow. Combined scores had a larger area under the curve than the SYNTAX score alone (0.78 [0.73-0.82] vs 0.73 [0.68-0.78], p=0.03). Analyses of both categorical (0.11 [0.01-0.22], p=0.02), and continuous net reclassification improvement (NRI>0) (0.54 [0.035-0.73], p<0.001) showed improvement in the predictive ability of no-reflow in the combined model, with integrated discrimination improvement (IDI) of 0.07 (0.04-0.09, p<0.001). Conclusions Our findings suggest that, in patients with STEMI undergoing percutaneous coronary intervention, atherosclerotic burden and thrombus burden in the culprit artery add predictive value to the SYNTAX score in detecting the no-reflow phenomenon. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Clinical characteristics and prognosis of young (<35 years) patients with acute ST-segment elevation myocardial infarction / 中华心血管病杂志

Objective: To analyze the risk factors and clinical characteristics as well as long-term prognosis of young patients (aged 18-35 years) with acute ST-segment elevation myocardial infarction (STEMI). Methods: In this retrospective study, from January 2007 to December 2017, STEMI patients who were hospitalized in Beijing Anzhen Hospital, Capital Medical University and younger than 45 years old were collected. Patients were divided to the 18-35 years old group and 36-44 years old group. The basic information of patients, clinical laboratory results, surgical information and discharge diagnosis of enrolled patients were extracted from the electronic medical record system. Subgroup analysis on STEMI patients aged 18 to 35 years was performed to compare the clinical features and outcome of patients with normal coronary angiography or stenotic coronary angiography. Results: 496 patients (20.3%) were between 18 and 35 years old, 480 cases (96.8%) were men, and 371 cases (74.8%) were smokers. The proportion of hypertension and diabetes was lower, but percent of obese (122 cases (43.3%)), level of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), uric acid and homocysteine ​​(Hcy) were significantly higher in patients aged 18 to 35 years compared with STEMI patients aged 36 to 44 years (all P<0.05). In the 18-35 years old group, there were 53 patients (10.7%) with normal coronary angiography and 443 patients (89.3%) with stenosis. The age, proportion of hypertension and diabetes, TC, LDL-C, and triglyceride (TG) levels were lower in the normal coronary angiography group than those in the coronary artery stenosis group (all P<0.05). The main coronary artery lesions were single vessel lesions (263 cases (59.4%)), and the main culprit vessels were left anterior descending artery lesions (238 cases (53.7%)). The follow-up time was 7.0 (4.0, 10.0) years, cardiovascular events were reported in 62 patients (18.9%), of which 14 patients (3.2%) died. The survival rate of patients without cardiovascular events in normal coronary angiography group was higher than that in stenosis group (P=0.029). Multivariate Cox regression analysis showed that diabetes (HR=2.713, 95%CI 1.479-4.976, P=0.001) and dyslipidemia (HR=2.819, 95%CI 1.564-5.079, P=0.001) were independent risk factors for recurrence of cardiovascular events in adult STEMI patients aged 18 to 35 years. Conclusions: STEMI patients aged 18 to 35 years were featured by male sex, obese and smokers. The proportion of hypertension and diabetes was low, while the levels of LDL-C, uric acid and Hcy were high in these patients. Coronary artery stenosis was common, and the stenosis was more likely to occur in the left anterior descending branch. Patients with normal coronary angiography had a better prognosis than those with stenosis. Diabetes and hyperlipidemia increased the risk of recurrent cardiovascular events.

Predictive value of ATRIA risk score for contrast-induced nephropathy after percutaneous coronary intervention for ST-segment elevation myocardial infarction

SUMMARY BACKGROUND: The AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) risk score used to detect the thromboembolic and hemorrhagic risk in atrial fibrillation patients has been shown recently to predict poor clinical outcomes in patients with acute myocardial infarction (ACS), regardless of having atrial fibrillation (AF). We aimed to analyze the relationship between different risk scores and contrast-induced nephropathy (CIN) development in patients with ACS who underwent urgent percutaneous coronary intervention (PCI) and compare the predictive ability of the ATRIA risk score with the MEHRAN risk score. METHODS: We analyzed 429 patients having St-segment Elevation Myocardial Infarction (STEMI) who underwent urgent PCI between January 2016 and February 2017. Patients were divided into two groups: those with and those without CIN and both groups were compared according to clinical, laboratory, and demographic features, including the CHA2DS2-VASc and ATRIA risk score. Predictors of CIN were determined by multivariate regression analysis. Receiver operating characteristics (ROC) curve analysis was used to analyze the prognostic value of CHA2DS2-VASc and ATRIA risk score for CIN, following STEMI. RESULTS: Multivariate regression analysis showed that Athe TRIA risk score, Opaque/Creatinine Clearance ratio, and low left ventricular ejection fraction was an independent predictor of CIN. The C-statistics for the ATRIA risk score and CHA2DS2-VASC risk score were 0.66 and 0.64 (p<0.001, and p<0.001), respectively. A pair-wise comparison of ROC curves showed that both scores were not inferior to the MEHRAN score in predicting CIN. CONCLUSION: The ATRIA and CHA2DS2-VASC scoring systems were useful for detecting CIN following STEMI.

RESUMO OBJETIVO: O escore Anticoagulação e Fatores de Risco na Fibrilação Atrial (Atria), usado na detecção do risco tromboembólico e hemorrágico de pacientes com fibrilação atrial (FA), recentemente demonstrou predizer resultados clínicos ruins em pacientes com infarto agudo do miocárdio (SCA), independentemente de ter FA. Nosso objetivo foi analisar a relação entre os diferentes escores de risco e o desenvolvimento de nefropatia induzida por contraste (NIC) em pacientes com SCA submetidos à intervenção coronária percutânea (ICP) urgente e comparar a capacidade preditiva do escore de risco Atria com o escore de risco Mehran. MÉTODOS: Foram analisados 429 pacientes com infarto agudo do miocárdio com elevação do segmento ST (IAM-ST) submetidos à ICP de urgência entre janeiro de 2016 e fevereiro de 2017. Os pacientes foram divididos em dois grupos: aqueles com e sem NIC, e ambos os grupos foram comparados de acordo com as características clínicas, laboratoriais e demográficas, incluindo os escores de risco CHA2DS2-VASc e Atria. Preditores de NIC foram determinados por análise de regressão multivariada. A análise da curva características de operação do receptor (ROC) foi utilizada para analisar o valor prognóstico dos escores de risco CHA2DS2-VASc e Atria para NIC, após IAM-ST. RESULTADOS: A análise de regressão multivariada mostrou que o escore de risco Atria, a relação opaca/crCl e a baixa fração de ejeção do ventrículo esquerdo foram preditores independentes de NIC. A estatística-C para o escore de risco Atria e o escore de risco CHA2DS2-VASC foi de 0,66 e 0,64 (p<0,001 e p<0,001), respectivamente. Uma comparação de pares de curvas características de operação do receptor mostrou que ambos os escores foram não inferiores ao escore Mehran na previsão de NIC. CONCLUSÃO: Os sistemas de pontuação Atria e CHA2DS2-VASC foram sistemas úteis para a detecção de NIC após IAM-ST.

Regional QT Interval Dispersion as an Early Predictor of Reperfusion in Patients with Acute Myocardial Infarction after Fibrinolytic Therapy / A Dispersão do Intervalo QT Regional como Preditor Precoce de Reperfusão em Pacientes com Infarto Agudo do Miocárdio Pós-terapia Fibrinolítica

Abstract Background: Patients with ST-elevation acute myocardial infarction attending primary care centers, treated with pharmaco-invasive strategy, are submitted to coronary angiography within 2-24 hours of fibrinolytic treatment. In this context, the knowledge about biomarkers of reperfusion, such as 50% ST-segment resolution is crucial. Objective: To evaluate the performance of QT interval dispersion in addition to other classical criteria, as an early marker of reperfusion after thrombolytic therapy. Methods: Observational study including 104 patients treated with tenecteplase (TNK), referred for a tertiary hospital. Electrocardiographic analysis consisted of measurements of the QT interval and QT dispersion in the 12 leads or in the ST-segment elevation area prior to and 60 minutes after TNK administration. All patients underwent angiography, with determination of TIMI flow and Blush grade in the culprit artery. P-values < 0.05 were considered statistically significant. Results: We found an increase in regional dispersion of the QT interval, corrected for heart rate (regional QTcD) 60 minutes after thrombolysis (p = 0.06) in anterior wall infarction in patients with TIMI flow 3 and Blush grade 3 [T3B3(+)]. When regional QTcD was added to the electrocardiographic criteria for reperfusion (i.e., > 50% ST-segment resolution), the area under the curve increased to 0.87 [(0.78-0.96). 95% IC. p < 0.001] in patients with coronary flow of T3B3(+). In patients with ST-segment resolution >50% and regional QTcD > 13 ms, we found a 93% sensitivity and 71% specificity for reperfusion in T3B3(+), and 6% of patients with successful reperfusion were reclassified. Conclusion: Our data suggest that regional QTcD is a promising non-invasive instrument for detection of reperfusion in the culprit artery 60 minutes after thrombolysis.

Resumo Fundamento: Pacientes com infarto do miocárdico com elevação do segmento-ST atendidos em centros de atendimento primário e tratados de acordo com a estratégia fármaco-invasiva são submetidos à fibrinólise seguida de coronariografia em período de 2-24h. Neste cenário, o conhecimento de marcadores de reperfusão como a redução em 50% do segmento-ST é fundamental. Objetivo: Analisar o desempenho da dispersão do intervalo QT em adição aos critérios clássicos, como marcador precoce de reperfusão pós-terapia trombolítica. Métodos: Estudo observacional com a inclusão de 104 pacientes tratados com tenecteplase (TNKase) e referenciados a hospital de atendimento terciário. A análise dos eletrocardiogramas (ECG) consistiu em mensuração do intervalo QT e sua dispersão nas 12 derivações, e também apenas na região com supradesnivelamento-ST antes e 60min pós-TNKase. A angiografia foi realizada em todos os pacientes com obtenção do fluxo TIMI e Blush da artéria culpada. Foram considerados significantes valores de p < 0,05. Resultados: Observamos aumento da dispersão do intervalo QT, corrigido pela frequência cardíaca, regional (dQTcR) 60min pós-lise (p = 0,006) em infartos de parede anterior nos casos com fluxo TIMI 3 e Blush 3 [T3B3(+)]. Adicionando a dQTcR ao critério ECG (redução do ST > 50%) de reperfusão, a área sob a curva aumentou para 0,87 [(0,78-0,96), IC95%, p < 0,001] em pacientes com fluxo coronário T3B3(+). Nos pacientes com critério de ECG para reperfusão e dQTcR > 13 ms a sensibilidade e especificidade foram 93% e 71%, respectivamente, para reperfusão em T3B3(+), possibilitando reclassificar 6% dos pacientes com sucesso de reperfusão. Conclusão: Os dados sugerem a dQTcR como instrumento promissor na identificação não invasiva de reperfusão na artéria coronária culpada, 60min pós-trombólise.

Disección espontánea de la arteria descendente anterior en gestante con desprendimiento prematuro de placenta normoinserta: reporte de caso / Case report spontaneous descending artery dissection in pregnant woman with premature placental abruption

La patología coronaria no es frecuente dentro de la población joven. El diagnóstico en la paciente obstétrica no es fácil dado los cambios fisiológicos que esta población presenta. La disección espontánea de una arteria coronaria es una afección muy poco frecuente que puede ser causa de isquemia miocárdica y asociarse a un síndrome coronario agudo. Se trata del caso de una paciente de sexo femenino de 38 años cursando 33 semanas de gestación, la cual presentó un síndrome coronario agudo con elevación del segmento ST, por una disección coronaria, desprendimiento prematuro de placenta normo inserta (DPPNI) y óbito fetal.

Coronary disease is infrequent among young population. Diagnosis in the obstetric population is not easy, due to the physiological changes that this population presents. Spontaneous coronary artery dissection, not a frequent medical condition, can be a cause of myocardial ischemia and be associated with and acute coronary syndrome. We present the case of a 38-year-old female patient, at 33 weeks gestation, who presented an acute coronary syndrome with ST segment elevation, caused by coronary artery dissection. This syndrome was accompanied with abruptio placentae and fetal death.

Correlation between GDF-15 gene polymorphism and the formation of collateral circulation in acute ST-elevation myocardial infarction

Summary Objective: To explore the correlation between growth differentiation factor 15 (GDF-15) -3148C/G polymorphism and the formation of collateral circulation in acute ST-elevation myocardial infarction (STEMI) in Han population of Taiyuan area. Method: The present study included 92 STEMI patients and 56 normal controls based on coronary angiography; STEMI group was divided into collateral group and non-collateral group according to Rentrop's grading method. Polymerase chain reaction (PCR) and DNA sequencing methods were used to detect and analyze the GDF-15 -3148C/G polymorphism in all participants. Results: There was significant difference in GDF-15 -3148C/G CC and GC distribution between STEMI group and control group (p=0.009); the allele frequencies between these two groups were also significant different (p=0.016); and the risk genotype for STEMI was CC with increased OR=2.660. For STEMI group, GDF-15 -3148C/G CC and GC distribution was also significantly different between patients with and without collateral (p=0.048), and CC genotype significantly promote the formation of collateral circulation. However, there were no significant differences in allele frequencies between these two subgroups of STEMI. Conclusion: There was correlation between GDF-15-3148C/G polymorphism and the formation of collateral circulation in patients with acute STEMI.