The Impact of SARS-CoV-2 on ST-Elevation Myocardial Infarction Volume, Time to Presentation, and Door-to-Balloon Time: A Report from a High-Volume Statewide Primary Percutaneous Intervention Program.

BACKGROUND: The novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) outbreak has affected ST-elevation myocardial infarction (STEMI) care worldwide. Reports from China, Europa, and North America showed a significant decline in STEMI volume with a simultaneous increase in time from symptoms to hospital presentation. AIM: The aim of the study was to study the effect of the SARS-CoV-2 outbreak on primary percutaneous coronary intervention (PPCI) volume performed for STEMI, symptom onset to hospital presentation time (symptom-to-door [S2D]), and door-to-balloon time (D2B) at the main nationwide PPCI center in Qatar. METHODS: A retrospective evaluation of prospectively collected quality improvement cardiac catheterization data in Qatar was performed. PPCI volume and S2D and D2B time during the outbreak from March 9, 2020, to May 14, 2020, were compared with that of the same period from the prior year and the period immediately preceding the outbreak. RESULTS: Since the SARS-CoV-2 outbreak in Qatar, 137 PPCI procedures were performed. There was a 40% reduction in the volume of PPCI when compared with the period immediately preceding the outbreak and 16% reduction in volume when compared with that of the same period in 2019. The median S2D time was 115 min (interquartile range [IQR: 124]), which was not statistically different from that of the preceding period or the same period in 2019. D2B time during the outbreak increased by an average of 7 min when compared with that of the same period preceding the outbreak (median: 47 min [IQR: 28] during the outbreak vs. median: 40 min [IQR: 21] during the preceding period, P = 0.016). CONCLUSION: In a statewide PPCI program in Qatar, we observed a mild reduction in PPCI cases during the SARS-CoV-2 outbreak (16% when compared with the same period in 2019), with a modest increase in D2B time. PPCI can be performed effectively during the SARS-CoV-2 outbreak at very high-volume centers with the adoption of strict infection control measures. With proper training and monitoring, both target D2B and hospital staff safety can be achieved.

Rheumatic Mitral Stenosis with Incidental Wolff-Parkinson-White Syndrome: A Rare Association. Treated by Percutaneous Transmitral Commissurotomy and Radiofrequency Ablation.

The combination of Wolff-Parkinson-White (WPW) syndrome and rheumatic mitral stenosis (MS) is rare in clinical practice. The management of this condition primarily depends on the clinical picture. We describe a 26-year-old male patient with no significant previous medical history and who came for a routine medical assessment before entrance to a police academy service. He was found to have rheumatic MS and WPW.

Impact of Polypharmacy on Adherence to Evidence-Based Medication in Patients who Underwent Percutaneous Coronary Intervention.

BACKGROUND: The primary objective of this study was to evaluate the impact of polypharmacy on primary and secondary adherence to evidence-based medication (EBM) and to measure factors associated with non-adherence among patients who underwent percutaneous coronary intervention (PCI). METHODS: We conducted a retrospective analysis for patients who underwent PCI at a tertiary cardiac care hospital in Qatar. Patients who had polypharmacy (defined as ≥6 medications) were compared with those who had no polypharmacy at hospital discharge in terms of primary and secondary adherence to dual antiplatelet therapy (DAPT), beta-blockers (BB), angiotensin converting enzyme inhibitors (ACEIs) and statins. RESULTS: A total of 557 patients (mean age: 53±10 years; 85%; males) who underwent PCI were included. The majority of patients (84.6%) received ≥6 medications (polypharmacy group) while only 15.4% patients received ≥5 medications (nonpolypharmacy group). The two groups were comparable in term of gender, nationality, socioeconomic status and medical insurance. The non-polypharmacy patients had significantly higher adherence to first refill of DAPT compared with patients in the polypharmacy group (100 vs. 76.9%; p=0.001). Similarly, the non-polypharmacy patients were significantly more adherent to secondary preventive medications (BB, ACEI and statins) than the polypharmacy group. CONCLUSION: In patients who underwent PCI, polypharmacy at discharge could play a negative role in the adherence to the first refill of EBM. Further studies should investigate other parameters that contribute to long term non-adherence.

Primary coronary angioplasty for ST-Elevation Myocardial Infarction in Qatar: First nationwide program.

In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as 'high volume', both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.

Right atrial infarction, atrial arrhythmia and inferior myocardial infarction form a missed triad: a case report and review of the literature.

Atrial infarction is rarely diagnosed before death because of its characteristically subtle and nonspecific electrocardiographic findings. These findings may be overshadowed by changes associated with concomitant ventricular infarction. A case of right atrial infarction accompanied by inferior myocardial infarction with rapid decompensated atrial fibrillation is reported. To increase awareness and knowledge of a complicated diagnosis, the present case is described in the context of a review of the relevant literature.

Detection of myocardial dysfunction in the presence of normal ejection fraction.

Detection of subclinical myocardial involvement is of utmost importance in risk stratification and prognosis; the role of ejection fraction in the detection of subclinical disease may be unhelpful. Our aim was to evaluate the methodology and importance of early detection of myocardial involvement in the presence of normal ejection fraction. Most of the pertinent English and non-English articles published from 1980 to 2006 in Medline, Scopus, and EBSCO Host research databases have been reviewed. Serial assessment of systolic function with different techniques should be avoided, since imaging modalities and ejection fraction measurements are not interchangeable. Additional non-invasive tools still are needed for the identification of subclinical left ventricular dysfunction in certain diseases. The recognition of subclinical involvement will prompt initiation of specific therapy to prevent the development of overt left ventricular dysfunction. This also is needed for determining the best timing for intervention in asymptomatic patients with metabolic and valvular disorders.

Obesity: a risk factor for acute myocardial infarction with angiographically patent epicardial coronary vessels in an adolescent.

OBJECTIVE: Toreport a causal relationship between myocardial infarction (MI) and obesity in an adolescent in the absence of the well-known risk factors for MI. CASE PRESENTATION AND INTERVENTION: A morbidly obese 17-year-old male, a nonsmoker, nondiabetic and normotensive patient, who sustained acute inferior MI with no family history of coronary artery disease, presented with central chest pain. ECG showed low voltage, normal sinus rhythm and ST segment elevation in the inferior leads; cardiac enzymes were elevated. Screening for ethanol and cocaine were negative. He was admitted to the coronary-care unit as a case of inferior MI with late presentation. Cardiac catheterization revealed patent epicardial coronary arteries; short- and long-term plans for weight reduction and family counseling were started. The hospital stay was uneventful, and the patient was discharged home on the fourth day. CONCLUSION: Based on clinical and laboratory findings, we assume that the MI might partly be secondary to coronary artery spasm or invisible premature atherosclerotic plaques. Public education and awareness for this complication in a young obese patient are warranted.

Intracardiac shunting of ruptured Sinus of Valsalva aneurysm in a patient presented with acute myocardial infarction: role of 64-slice MDCT.

Rupture of Sinus of Valsalva aneurysm (SVA) may be either congenital or acquired. This report describes a case of intracardiac shunting of a ruptured SVA of atherosclerotic origin to the right atrium, presenting with acute myocardial infarction. The sinus of Valsalva aneurysm and the intracardiac shunt track into the right atrium was not defined by the two-dimensional echocardiography could be seen by 64-slice multi detector computed tomography (MDCT).

Acute myocardial infarction with patent epicardial coronary vessels following Cassia italica ingestion.

Herbal intake is escalating worldwide. To the best of our knowledge, myocardial infarction (MI) has not been reported following ingestion of laxative herbs in the absence of the well known risk factors for MI. We report on a 45- yr-old female patient who sustained acute inferior MI 8 h following Cassia italica ingestion. Subsequently, cardiac catheterization revealed patent coronary arteries. We assume that, in this case, MI may partly be related herbal ingestion. Further studies and public awareness of this complication in certain communities are needed.