In this study we report the histopathological characteristics of material obtained from a large consecutive cohort of STEMI patients treated with thrombus aspiration in adjunct to conventional primary PCI. Aspirated material could histopathologically be confirmed in 74% of the patients. The obtained thrombus material showed lytic or organized changes in 40% of the patients, indicating the thrombus is older than 24 hours in a significant proportion of STEMI patientswith onset of symptoms less than 12 hours before. We found older thrombus (more than one day) in a substantial proportion of the STEMI patients (40%) and the composition of the these thrombi was often heterogeneous, showing in part featuresof fresh, of lytic, and organized thrombus. These results support the concept ofcoronary artery disease as a dynamic process. Disruption of atherosclerotic plaques may act as a stimulus for repeated or ongoing thrombosis, which ultimately progresses over a period of days or even weeks to thrombotic occlusion with a secondary fresh thrombus. Systematic histopath- ological analyses of the atherothrombotic material obtained with thrombus aspiration during primary PCI in large patient cohorts are limited. Our findings are in line with our previous results that describe histopathological analyses ofaspirated atherothrombotic material in a smaller group of 211 STEMI patientsin whom we identified older thrombus in approximately 50% ofpatients. The insights in the mechanisms ofcoronary thrombosis mainly come from detailed analyses of underlying plaque morphologies in necropsy specimen from sudden death victims. Autopsy studies on the histopathology of the progression ofcoronary plaques demonstrated the occurrence of clinically silent coronary non- occlusive atherothrombotic events before the occlusive athero- thrombotic event.[2,7] Furthermore, multiple subclinical episodes of plaque disruption, followed by healing, are an important mechanism of atherosclerotic
In general, a dominant LCX has several acute angles in its course, including at its origin and at its distal end where it becomes the PDA. These acute angles lead to turbulence and shear stress during blood flow that, in turn, may enhance thrombus formation and platelet activity [19,20]. The acute angles, and resultant turbulence and shear stress, also contribute to the difficulty of LCX interventions. Yip et al. concluded that LD is related to unsuccessful reperfusion and to a higher 30-day mortality rate in LCX infarct-related acute myocardialinfarction (MI) patients . In addition, Auriti et al. showed that coronary flow reserve was more impaired in LCX than LAD just after Y-graft intervention, which was a graft formed by the left internal mammary artery (LIMA) connected to the LAD and by a free right internal mammary artery (RIMA) connected to LIMA and a marginal artery of the LCX . Clinically, a recent study showed that the 30-day prognostic outcome was less favorable in LCX- related acute inferior MI compared to RCA-related acute inferior MI . The reasons for this difference were suggested to include higher peak levels of creatine kinase-MB isoenzyme, lower left ventricular ejection fractions, and the higher numbers of advanced congestive heart failure that were observed in LCX-related acute inferior MIs. Lower rates of stent implantation and collateral circulation might also contribute to the worse outcomes. The study data did not indicate the manner in which dominance might affect mortality; Kim concluded patientswith an occluded LCX presented with less STelevation and primary PCI . Multivariate analysis showed that primary PCI decreased the hospital mortality for patientswith occluded coronary arteries. For these reasons, we suspect that more flow disturbances are induced, leading to more adverse effects on hemodynamics during PCI, inpatientswith PCI of a dominant LCX.
Primarypercutaneouscoronaryintervention (PCI) has become the favored reperfusion strategy in acute ST-segment elevationmyocardialinfarction. Lower post-PCI myocardial perfusion grade, no-reflow and even drug-eluting stent thrombosis have been related to the presence of intracoronary thrombus. Adjunctive thrombectomy refers to procedures and devices that remove thrombotic material from the infarction- related artery, in theory, before distal embolization can occur. There is substantial variability between randomized controlled trials of thrombectomy inprimary PCI with regards to tested devices, procedural characteristics, adjuvant medical regimen and examined outcomes. As a general statement, improvements inmyocardial perfusion endpoints do not translate into reductions in clinical outcomes. Yet, an increasing number of trials with a longer follow-up reported benefits arising late after the index myocardialinfarction. Simple aspiration catheters may also produce better outcomes than devices that fragment the thrombus before aspirating debris. Clinical or angiographic variables which best predict benefits from the use of thrombectomy remain to be defined. The aim of this review is to provide perspective on the conclusions of available trials and meta-analysis of adjunctive thrombectomy in acute myocardialinfarction. Targets for future studies are discussed.
No-reflow refers to a state ofmyocardial tissue hypo- perfusion in the presence of a patent epicardial coronary artery. The underlying cause of no-reflow is microvascular obstruction, which may be developed by various mechanisms. Reperfusion no-reflow occurs afterprimaryPercutaneousCoronaryIntervention (PCI) for reperfusion of an infarct-related artery in the setting of Acute MyocardialInfarction (AMI), which may be asymptomatic or clinically present with uncontrolled chest pain and ST-segment elevation. Reperfusion no-reflow is preceded by ischemic cell injury, confined to the irreversibly damaged necrotic zone, which can exacerbate at the time of reperfusion.
Background: Treatment ofST-elevation acute myocardialinfarction has primarypercutaneouscoronaryintervention as the preferred method of reperfusion. This study aimed to evaluate in-hospital outcomes ofpatientswithST-elevation acute myocardialinfarction according to the total ischemic time until performing primarypercutaneouscoronary interven- tion. Methods: Single-center registry ofpatients admitted withST-elevation acute myocardialinfarction undergoing primarypercutaneouscoronaryintervention between March/2012 and February/2014, followed from admission to hospital dis- charge, and compared according to the total ischemic time (Group 1: symptom onset-to-balloon time < 6 hours; Group 2: symptom onset-to-balloon time ≥ 6 and < 12 hours). Re- sults: Two hundred seventy nine patients underwent primarypercutaneouscoronaryintervention, 118 in Group 1 (42.3%) and 161 in Group 2 (57.7%). Group 2 was older, had higher prevalence of hypertension, fewer smokers, more patientsin Killip-Kimball class ≥ 2 and lower primarypercutaneouscoronaryintervention success rate. The incidences of death or non-fatal infarction (11.0% vs. 18.6%; p = 0.08), death (8.5% vs. 16.8%; p = 0.04) and acute renal failure (7.6% vs. 19.9%; p < 0.01) were greater in Group 2. Conclusions: PatientswithST-elevation acute myocardialinfarction undergoing primarypercutaneouscoronaryinterventionwith symptom onset-to- balloon time ≥ 6 hours presented higher clinical complexity and worse in-hospital outcomes when compared to patients treated earlier. Joint actions in different critical areas of patient care are essential to increase treatment eficacy and reduce adverse outcomes.
Statistical analysis was performed by using the SPSS 22.0 Statistical Package Program for Windows (SPSS Inc., Chicago, IL, USA). Continuous variables are presented as a mean ± standard deviation or as medians and interquartile ranges. The differences between groups of continuous variables with a normal distribution (age, LVEF, creatinine, stent parameters and hematological parameters) were tested by independent samples t-test, while skewed distribution variable (peak cardiac troponin I (cTnI)) were compared by the Mann-Whitney U test. Categorical variables were summarized as percentages and compared with the chi-square test. A univariate analysis was first performed to test for the association of the high-thrombus burden and several potentially impacting variables (age, sex, history of diabetes mellitus, prior myocardialinfarction (MI), LVEF, creatine level, time from symptom onset to PPCI, monocyte count, neutrophil count, lymphocyte count and hemoglobin level). Multivariate logistic regression analysis was then used to identify independent predictors of high thrombus burden using variables (prior MI, time from symptom onset to PPCI and monocyte count) that reached a trend-level effect (p < 0.1) in the univariate analyses. The receiver operating characteristics (ROC) curve was used to determine the cut-off value of monocyte count to predict the high-thrombus burden. A two-sided p-value of < 0.05 was considered significant.
19. Hoebers LP, Damman P, Claessen BE, Vis MM, Baan J Jr, van Straalen JP, et al. Predictive value of plasma glucose level on admission for short and long term mortality inpatientswithST-elevationmyocardialinfarction treated withprimarypercutaneouscoronaryintervention. Am J Cardiol. 2012;109(1):53-9. 20. Ergelen M, Uyarel H, Cicek G, Isik T, Osmonov D, Gunaydin ZY, et al. Which is worst inpatients undergoing primary angioplasty for acute myocardialinfarction? Hyperglycaemia? Diabetes mellitus? Or both? Acta Cardiol. 2010;65(4):415-23.
We did not have available ventricular function information from all patients, because left ventriculography is not routinely performed during catheterization and primarypercutaneouscoronaryintervention (pPCI) to minimize contrast volume. However, the percentage ofpatientswith previous CHF who presented with Killip III/IV class at the time of STEMI was similar, suggesting that left ventricular function in both groups was not significantly different. This was a single-center study in a large tertiary cardiology hospital, and the results shown herein may not be valid for populations that are significantly different from ours.
5. Garg S, Sarno G, Serruys PW, Rodriguez AE, Bolognese L, Anselmi M, et al; STRATEGY and MULTISTRATEGY Investigators. Prediction of 1-year clinical outcomes using the SYNTAX score inpatientswith acute ST-segment elevationmyocardialinfarction undergoing primarypercutaneouscoronaryintervention: a substudy of the STRATEGY (Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent Versus Abciximab and Bare-Metal Stent in Acute MyocardialInfarction) and MULTISTRATEGY (Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent in Acute MyocardialInfarction Study) trials. JACC Cardiovasc Interv. 2011;4(1):66-75. doi: 10.1016/j. jcin.2010.09.017.
The main limitation of this view ofcoronary microvascular dysfunction as a consequence of the myocardialinfarction relates to the fact that the studies that support it were not designed to evaluate if the abnormalities were already present before or during the myocardialinfarction, as opposed to after the event. Additionally, the plaque rupture theory has been challenged in recent years, with the finding that plaque rupture is much more common than previously thought and that most plaque ruptures remain clinically silent. The best evidence on this comes from the PROSPECT trial, in which 697 patientswith acute coronary syndromes underwent three-vessel coronary angiography and intravascular ultrasonographic imaging (IVUS) afterpercutaneouscoronaryintervention. Subsequent major adverse cardiovascular events, over a median follow-up time of 3.4 years, were found to be equally attributable to recurrence at the site of culprit lesions and to nonculprit lesions. 90 Additionally, in a substudy
background: Platelets play a key role in the pathophysiology of acute myocardialinfarction. There is evidence that higher platelet volumes may have increased prothrombotic potential. The aim of this study was to evaluate whether mean platelet volume can predict culprit coronary vessel low and adverse cardiovascular outcomes inpatientswithST-segment elevationmyocardialinfarction undergoing primarypercutaneouscoronaryintervention. Methods: Primary endpoint was the composite of adverse cardiovascular events (death, stroke, myocardialinfarction, stent thrombosis, class-III or IV angina and heart failure) at 30 days. The secondary endpoint was evaluated by the angiographic TIMI low grade after the procedure. results: Of the 215 patients included in the primarypercutaneouscoronaryintervention registry, 168 (78.6%) had their mean platelet volume calculated before the procedure and were analyzed in the present study. Mean platelet volume values were stratiied in tertiles, and a high value was considered as > 11 femtoliters (fL). Mean platelet volume > 11 fL was an independent predictor of cardiovascular events at 30 days (p = 0.02). It was observed that patientswith inal TIMI low grade zero or 1 showed a trend towards higher mean platelet volume compared with those with inal TIMI low 2 or 3 (11.3 ± 0.9 fL vs. 10.5 ± 1.3 fL; p = 0.06). Conclusions: Baseline mean platelet volume is a simple, useful, and easy to measure marker to predict the risk of cardiovascular events at 30 days inpatientswithST-segment elevationmyocardialinfarction undergoing primarypercutaneouscoronaryintervention. Future studies may answer whether more aggressive antithrombotic therapy results in better angiographic and/or clinical outcomes inpatientswith larger and more active platelets.
The patient remained clinically stable and was submitted to a new catheterization four days later, which persisted showing an image compatible with thrombus presence in the right coronary artery proximal segment, but smaller in size, when compared to the prior assessment, with no residual stenosis and TIMI-3 distal low (Figure 4). The echocardiography showed preserved left ventricular globaland segmental systolic functions with ejection fraction of 72%. In order to rule out the association with Moyamoya syndrome, a cerebrovascular alteration eventually observed inpatientswith sickle cell anemia that greatly increases the risk of intracranial bleeding in these individuals, whose presence could inluence the anticoagulation strategy after discharge, the patient underwent a cerebral angiography, which excluded such diagnosis. He showed clinical improvement and was discharged with a prescription for ASA, clopidogrel, warfarin, and simvastatin.
Paciente de 60 anos de idade, com histórico de implante de dois stents coronários não farmacológicos durante quadro de infarto do miocárdio com supra do segmento-ST. Dois anos após, foi admitido no pronto-socorro com quadro clínico de angina instável de início recente. O paciente fazia uso regular de inibidor da enzima de conversão da angiotensina, betabloqueador e aspirina. A aspirina foi suspensa por 10 dias antes da atual hospitalização para a retirada de um tumor de rim. O paciente foi submetido a angiografia coronária, que revelou artéria coronária direita com defeito de enchimento
RR = 0.88, 95% CI 0.56 to 1.38, p = 0.59, I 2 = 57%, Figure 2B; cardiac death: RR = 0.82, 95% CI 0.35 to 1.92, p = 0.65, I 2 = 12%, Figure 2C). Moreover, second-generation DES did not show the superiority in lowering the risk of recurrent myocardialinfarction (RR = 0.83, 95% CI 0.27 to 2.61, p = 0.75, I 2 = 53%, Figure 3A). Notably, the risk for TLR in ACS patients receiving second-generation DES treatment was over 2 times higher than the first-generation DES (RR = 2.08, 95%CI 1.25 to 3.47, p = 0.005, I 2 = 0%, Figure 3B). Conversely, the second-generation DES trended to be associated, albeit nonsignificantly, with decreased incidence of definite or probable stent thrombosis (RR = 0.60, 95%CI 0.33 to 1.07, p = 0.09, I 2 = 15%, Figure 3C). In addition, in acute myocardialinfarction (AMI) subgroup, there were no significant differences in the occurrence of MACEs and TLR between the two arms (Table 3). Nevertheless, compared with the first-generation DES, the second-generation DES might dramatically lower the risk of stent thrombosis by 54% (RR = 0.46, p = 0.01). However, when the analysis was restricted to unselected ACS patients, in which only one study (SORT OUT III ACS trial ) was enrolled, pooled results showed that the second- generation DES was inferior to the first-generation one in reducing the incidence of MACEs (p = 0.02) and TLR (p = 0.01). Nevertheless, the second-generation DES did not increase the risk of stent thrombosis compared with the first-generation one (p = 0.48). In ZES subgroup the second-generation DES showed an increased occurrence of MACEs (RR = 1.45, p = 0.02) and TLR (RR = 2.31, p = 0.003), while in EES subgroup a tendency to
Beira Hospital were analyzed. The following variables were studied: sex, age, traige flowchart assigned, type of acute myocardialinfarction, electrocardiogram performed in less than 10 minutes from the entrance of the emergency room and ‘door-to-needle’ times. Results: Of the 3 463 patientswith chest pain, 77.5% underwent electrocardiogram with a median electrocardiogram performed in less than 10 minutes from the entrance of the emergency room time of 19 minutes and only 23.4% performed it under 10 minutes. Inpatientswith acute myocardialinfarction, the average age in the chest pain flowchart was 66.0yo and 76.6yo for those triaged without chest pain. Chest pain was presented in 73.2% of acute ST-segment elevationmyocardialinfarction. In acute myocardialinfarction associated with chest pain, 54.7% were acute ST-segment elevationmyocardialinfarction and 43.5% were non- acute ST-segment elevationmyocardialinfarction. Of the 56 cases of acute ST-segment elevationmyocardialinfarction, 46.4% underwent fibrinolysis but only three performed it under 30 minutes. Conclusion: The coronary fast-track protocol needs to be more effective in carrying out electrocardiogram in less than 10 minutes inpatientswith chest pain. The fast-track activation based on chest pain triage is insufficient to early detect acute myocardialinfarction. The process to fibrinolysis should be facilitated to improve the recommended times.
It is important to identify which patient groups are more likely to have significantly longer pre-hospital delay and to determine their particular clinical and demographic characteristics. In our study, female patients and those with diabetes, hypertension and symptom onset between 10 pm and 8 am made up the majority of this group. Longer pre-hos- pital delay was associated with a lower proba- bility of being treated with reperfusion thera- py, a higher frequency of severely reduced LVEF and a non-significant increase inin- hospital mortality. Public campaigns are needed to raise awareness among the general population of the warning signs and symptoms that should prompt such patients to seek immediate medical attention at an emergency department. In the case of individual patients, many of whom have multiple cardiovascular risk factors, it is the responsibility of cardiol- ogists to carefully explain the importance of correcting risk factors and to describe the signs and symptoms suggestive ofmyocardialinfarction that should prompt them to seek medical attention in the emergency depart- ment.
Serão sempre anotados, em banco de dados pró- prio para este estudo, as características demográficas, clínicas, angiográficas e do procedimento de interven- ção terapêutica percutânea e seus resultados: idade, gênero, etnia, peso, altura, índice de massa corporal, antecedentes de diabetes mellitus, hipertensão arterial sistêmica, dislipidemia, status do tabagismo (atual; pré vio − se > 1 mês; ou nunca), obesidade, história fa miliar de doença coronária, infarto prévio, intervenção percutânea anterior em outra artéria, revascularização mio cárdica cirúrgica antiga, infarto atual de parede an terior, insuficiência cardíaca prévia, insuficiência car - díaca atual; os tempos de sintoma-primeiro atendi- mento médico, de sintoma-atendimento médico nesta instituição, de sintoma-ad ministração de fármacos, de sintoma-cateterismo diagnóstico, de sintoma-balão, de atendimento médico institucional-balão, de procedimento diagnóstico, de procedimento terapêutico; o uso prévio de ácido acetilsalicílico, betabloqueador, inibidor da enzima conversora de angiotensina, estati na, nitrato, droga ilícita; o antecedente de doença co ronária conhecida; pressão arterial sistólica < 100 mmHg, frequência cardíaca > 100 bpm, grau Killip-Kimball, acesso vascular (radial, braquial e femoral), artéria associada ao IMCSST atual (coronária direita, circunflexa, descendente anterior e tronco coronária esquerda), provável artéria associada com lesão < 50%; escore de fluxo TIMI-0, 1, 2 e 3, pré-procedimento e pós-procedimento; escore de opa- cificação miocárdica e escoamento MBG-0, 1, 2 e 3; tipo de lesão A, B ou C; presença de doença uniarterial, biarterial ou triarterial; ocorrência angiográfica de não reperfusão; emprego de fármacos intracoronarianos para tratar o FNR no laboratório de hemodinâmica (tri nitrato, adenosina, verapamil e nitroprussiato de sódio); resolução aceitável da não reperfusão; uso de aspirador manual de trombos; dor persistente ao final do procedimento (1 a 10); uso de morfina; uso de stent (um, dois ou três), tipo e dimensões do stent, im plante direto de stent, pré-dilatação com balão, pós- -dilatação com balão, pressão de liberação do stent, pressão de balão pós-stent, intervenção somente com balão (sem stent); pico de CK-MB, troponina, fração de ejeção ventricular esquerda; ocorrência de insu- cesso do procedimento; desvio do segmento ST pré e pós-procedimento (mm); e ocorrência de sangramento grave, moderado e mínimo. Será adotado o critério de definição TIMI para hemorragias: (1) sangramento grave, se hemorragia intracerebral, ou se quadro clínico
results of a study performed by Bertrand in 2010, 89.4% of the transradial PCIs performed worldwide were performed through right radial artery, and only 10.6% were performed through left radial artery (4). In China, many physicians have chosen to use the radial artery route to perform routine PCI; however, for emergency PCI, physicians still prefer using the femoral artery route because the radial artery procedure is associated with many drawbacks, for example, radial artery puncture, difficulties with catheter delivery, or inadequate conduit support. However, the femoral route is also asso- ciated with many severe vascular complications. The direc- tion from which the catheter enters the ascending aorta via the left radial artery is similar to that from which it enters the aorta via the femoral artery, and the left subclavian artery shows limited shape/directional variation; thus, choosing the left radial artery route for emergency PCI may enable clinicians to retain the advantages of the radial route and simultaneously avoid the disadvantages of the femoral route and thus should result in satisfactory outcomes. Therefore, in the current study, we assigned 206 patients who recently underwent emergency PCI in our hospital into the indicated two groups (a left radial artery group and a femoral artery group) and compared the two groups with respect to several parameters. We found that emergency PCI through the left radial route can achieve catheter placement results similar to those of the femoral artery route and is as fast and as safe as its counterpart. More importantly, PCI through the left radial route significantly decreased the occurrence of vascular complications, especially complications that were unaccep- table to patients. The two groups had similar overall patient prognoses after PCI. This result is consistent with those of the TCT2012 reports, which found that transradial access reduced the risk of bleeding in high-risk acute coronary syn- drome (ACS) patients (5). A more recent study has confirmed this conclusion (6).
Background: Aspiration thrombectomy is recommended as an adjunctive method inpatients undergoing primary percutane- ous coronaryintervention (PCI), however, thrombus aspiration failure is relatively frequent. The objective of this study was to evaluate the rate and identify predictors of failed thrombus aspiration in a contemporaneous series ofpatients. Methods: Prospective cohort study including consecutive patientswith acute ST-segment elevationmyocardialinfarction undergoing primary PCI with thrombus aspiration from December 2009 to December 2011. Aspiration thrombectomy was performed at the operator’s discretion and success was deined as ef- fective thrombus aspiration by a dedicated catheter with the achievement of a inal TIMI low > 0. Results: 1,055 primary PCIs were performed and aspiration thrombectomy was used in 37% of cases with a success rate of 70%. Aspiration thrombectomy success was observed in 254 patients whereas failure was observed in 107 patients. Aspiration thrombectomy failure was associated with age, hypertension, diabetes mel- litus , dyslipidemia, previous PCI, TIMI risk score, Killip IV, leukocyte count, serum ibrinogen, target vessel reference diameter and preprocedural TIMI 3 low. Patientswith failed thrombus aspiration had a trend towards higher mortality (11.6% vs. 5.9%; P = 0.09). Conclusions: Aspiration thrombectomy failure during primary PCI was observed in 30% of the cases and was associated with a trend towards higher mortality. The identiication of clinical, laboratory and angiographic predic- tors may help improve these devices and the technique and enable better patient selection.