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This study aimed to validate an inflammation-based risk score in patients with ST-segment elevation myocardial infarction (STEMI) by examining their cytokine profiles. Upon admission, patients were evaluated for systemic inflammation using a risk score that assigned points based on specific biomarkers: 1 point for leukocyte count ≥9.3 × 10³ cells/µL, 2 points for high-sensitivity C-reactive protein (hsCRP) ≥13.0 mg/L, and 3 points for serum albumin ≤3.6 g/dL. Patients were categorized into three groups: no inflammation (0 points, n = 13), mild inflammation (1-2 points, n = 35), and severe inflammation (3-6 points, n = 26). Serum levels of 16 key cytokines were measured. Patients with higher risk scores showed elevated interleukin (IL)-6 levels (19.6 vs. 8.5 vs. 6.8 pg/mL; P = 0.021) and decreased interferon-γ-induced protein-10 (IP-10) levels (73.4 vs. 68.8 vs. 112.2 pg/mL; P = 0.011). IL-6 was positively correlated with hsCRP (ρ 0.307) and negatively correlated with albumin (ρ -0.298), while IP-10 was negatively correlated with leukocyte count (ρ -0.301). No other cytokines showed significant association with the risk score. Higher inflammation scores were also associated with an increased incidence of major adverse cardiovascular events, particularly acute heart failure. This study underscores the association between the inflammation-based risk score and cytokine levels, specifically IL-6 and IP-10, in patients with STEMI.
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Background: No-reflow (NRF) phenomenon is a significant challenge in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). Accurate prediction of NRF may help improve clinical outcomes of patients. This retrospective study aimed at creating an optimal model based on machine learning (ML) to predict NRF in these patients, with the additional objective of guiding pre- and intra-operative decision-making to reduce NRF incidence. Methods: Data were collected from 321 STEMI patients undergoing pPCI between January 2022 and May 2023, with the dataset being randomly divided into training and internal validation sets in a 7:3 ratio. Selected features included pre- and intra-operative demographic data, laboratory parameters, electrocardiogram, comorbidities, patients' clinical status, coronary angiographic data, and intraoperative interventions. Post comprehensive feature cleaning and engineering, three logistic regression (LR) models [LR-classic, LR-random forest (LR-RF), and LR-eXtreme Gradient Boosting (LR-XGB)], a RF model and an eXtreme Gradient Boosting (XGBoost) model were developed within the training set, followed by performance evaluation on the internal validation sets. Results: Among the 261 patients who met the inclusion criteria, 212 were allocated to the normal flow group and 49 to the NRF group. The training group consisted of 183 patients, while the internal validation group included 78 patients. The LR-XGB model, with an area under the curve (AUC) of 0.829 [95% confidence interval (CI): 0.779-0.880], was selected as the representative model for logistic regression analyses. The LR model had an AUC slightly lower than XGBoost model (AUC 0.835, 95% CI: 0.781-0.889) but significantly higher than RF model (AUC 0.731, 95% CI: 0.660-0.802). Internal validation underscored the unique advantages of each model, with the LR model demonstrating the highest clinical net benefit at relevant thresholds, as determined by decision curve analysis. The LR model encompassed seven meaningful features, and notably, thrombolysis in myocardial infarction flow after initial balloon dilation (TFAID) was the most impactful predictor in all models. A web-based application based on the LR model, hosting these predictive models, is available at https://l7173o-wang-lyn.shinyapps.io/shiny-1/. Conclusions: A LR model was successfully developed through ML to forecast NRF phenomena in STEMI patients undergoing pPCI. A web-based application derived from the LR model facilitates clinical implementation.
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BACKGROUND: The extent to which infarct artery impacts the extent of myocardial injury and outcomes in patients with ST-segment-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention is uncertain. METHODS AND RESULTS: We performed a pooled analysis using individual patient data from 7 randomized STEMI trials in which myocardial injury within 30 days after primary percutaneous coronary intervention was assessed in 1774 patients by cardiac magnetic resonance (n=1318) or technetium-99m sestamibi single-photon emission computed tomography (n=456). Clinical follow-up was performed at a median duration of 351 days (interquartile range, 184-368 days). Infarct size and outcomes were assessed in anterior (infarct vessel=left anterior descending) versus nonanterior (non-left anterior descending) STEMI. Median infarct size (percentage left ventricular myocardial mass) was larger in patients with anterior compared with nonanterior STEMI (19.7% [interquartile range, 9.4%-31.7%] versus 12.6% [interquartile range, 5.1%-20.5%]; P<0.001). Patients with anterior compared with nonanterior STEMI were at higher risk for 1-year all-cause mortality (6.2% versus 3.6%; adjusted hazard ratio [HR], 1.66 [95% CI, 1.02-2.69]; P=0.04) and heart failure hospitalization (4.4% versus 2.6%; adjusted HR, 1.96 [95% CI, 1.15-3.36]; P=0.01). Infarct size was a predictor of subsequent all-cause mortality or heart failure hospitalization in anterior STEMI (adjusted HR per 1% increase, 1.05 [95% CI, 1.03-1.07]; P<0.001), but not in nonanterior STEMI (adjusted HR, 1.02 [95% CI, 0.99-1.05]; P=0.19). The P value for this interaction was 0.04. CONCLUSIONS: Anterior STEMI was associated with substantially greater myonecrosis after primary percutaneous coronary intervention compared with nonanterior STEMI, contributing in large part to the worse prognosis in patients with anterior infarction.
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Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Tomografia Computadorizada de Emissão de Fóton Único , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Resultado do Tratamento , Miocárdio/patologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Fatores de Risco , Tecnécio Tc 99m Sestamibi , Infarto Miocárdico de Parede Anterior/terapia , Infarto Miocárdico de Parede Anterior/diagnóstico por imagem , Infarto Miocárdico de Parede Anterior/cirurgiaRESUMO
Background: The relationship between the triglyceride-glucose (TyG) index and no-reflow phenomenon after percutaneous coronary intervention (PCI) in patients with type 2 diabetes mellitus (T2DM) and acute ST-segment elevation myocardial infarction (STEMI) remains unclear. This study aimed to investigate the relationship between baseline TyG index and no-reflow phenomenon in STEMI patients with T2DM after PCI. Methods: This study enrolled 695 patients with T2DM and STEMI from the General Hospital of Ningxia Medical University (2014-2019). Patients were divided into tertiles according to the TyG index levels. The incidence of no-reflow phenomenon was recorded. A multivariate regression model was developed to analyze the association between the baseline TyG index and no-reflow phenomenon. The linear association between the baseline TyG index and no-reflow phenomenon was explored using smooth curve fitting with parallel subgroup analyses. Receiver operating characteristic (ROC) curves were generated to determine the predictive power of the TyG index. Results: A multivariate logistic regression model revealed that the TyG index was an independent risk factor of no-reflow phenomenon [OR = 3.23, 95%CI: 2.15-4.86, P < 0.001], and the occurrence of no-reflow phenomenon increased gradually with the increase of TyG index tertile interval (P < 0.001). Smooth curve fitting showed that the TyG index was linearly related to the risk of no-reflow. Subgroup analysis showed that they participated in this positive correlation. The area under the ROC curve (AUC) of the TyG index for evaluating the occurrence of no-reflow was 0.710 (95% CI: 0.640-0.780; P < 0.01). Conclusions: The TyG index is independently associated with no-reflow phenomenon, suggesting that the simple index of the TyG index can be used for risk assessment of no-reflow phenomenon after PCI in STEMI patients with T2DM.
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INTRODUCTION AND OBJECTIVES: Invasive management in frail patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains controversial. We investigated the impact of various geriatric conditions. METHODS: The MOSCA-FRAIL trial included 167 adults aged ≥ 70 years with frailty (Clinical Frailty Scale [CFS] ≥ 4 points) and NSTEMI, who were randomized to either an invasive (n=84) or conservative (n=83) strategy. In addition to frailty, we measured activities of daily living (Barthel index), cognitive impairment (Pfeiffer test), and comorbidities (Charlson index). The primary endpoint was the difference (invasive minus conservative) in restricted mean survival time (RMST) for all-cause mortality at a median follow-up of 3.9 years. RESULTS: A total of 93 patients died. The RMST difference favored invasive management at the CFS 25th percentile (CFS=4; 157 days, 95%CI, 18-295; P=.027), which changed to a nonsignificant effect at the 50th and 75th percentiles. The RMST difference remained nonsignificant, irrespective of the severity of other geriatric assessments. In time-to-event analysis, invasive management was associated with an initially lower life expectancy, peaking at around 1 year, among all subgroups. However, patients with CFS=4 experienced a benefit at the end of follow-up (181 days, 95%CI, 19-343), whereas those with CFS >4 did not (-16 days, 95%CI, -217 to 186; interaction P=.16). Subgroups defined by other geriatric markers showed a similar time-dependent trend, albeit with weaker statistical interaction. CONCLUSIONS: Among adults with frailty and NSTEMI, the CFS might be useful for evaluating the relative risks and benefits of invasive management. A CFS >4 could serve as a valuable threshold for decision-making.
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Objective Triple-vessel disease (TVD) is a well-established prognostic factor for patients with acute myocardial infarction (AMI). However, there is a paucity of literature regarding the risk factors for in-hospital death in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and TVD. In this retrospective study, we examined the determinants of in-hospital death in patients with NSTEMI and TVD who underwent percutaneous coronary intervention (PCI) for culprit lesions. Methods The primary objective of this study was to identify the factors associated with in-hospital death using a multivariate analysis. We included 253 patients with NSTEMI and TVD and divided them into a survivor group (n=239) and an in-hospital death group (n=14). Results Systolic blood pressure (SBP) at admission was significantly higher in the survivor group than in the in-hospital death group. The estimated glomerular filtration rate (eGFR) was also higher in the survivor group than in the in-hospital death group. In the multivariate logistic regression analysis, in-hospital death was inversely associated with the SBP at admission (odds ratio [OR] 0.984, 95% confidence interval [CI] 0.970-0.999, p<0.035) and eGFR (OR 0.966, 95% CI 0.939-0.994, p=0.019) and was associated with cardiopulmonary arrest (CPA) before PCI (OR 8.448, 95%CI 1.863-38.309, p=0.006). Conclusion In-hospital death was associated with CPA before PCI and inversely associated with the SBP at admission and eGFR in patients with NSTEMI and TVD who underwent PCI for the culprit lesion. It may be important to recognize these high-risk features in order to improve the clinical outcomes of patients with NSTEMI and TVD.
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PURPOSE: System delay is associated with mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). However, the influence of patient delay has been relatively overlooked. We aimed to evaluate the influence of patient and system delays on STEMI patients undergoing primary PCI in China. METHODS: STEMI patients registered at the Nationwide Chinese Cardiovascular Association Database-Chest Pain Center from January 2017 to September 2021 were screened. The exposures were total ischemic time (TIT), system delay and patient delay. The primary outcome was in-hospital mortality. RESULTS: Among 458,260 patients from 2,529 centers, median TIT, system delay and patient delay were 4.1, 1.5 and 2.1 hours, respectively. The adjusted odds ratio of in-hospital mortality increased by 2.2% (odds ratio [OR], 1.022, 95% confidence interval [CI], 1.017-1.027), 2.3% (1.023, 1.006-1.040) and 2.2% (1.022, 1.017-1.027) for every one-hour increase in TIT, system delay and patient delay, respectively. CONCLUSIONS: Patient delay demonstrated a comparable impact to system delay on in-hospital mortality among STEMI patients undergoing primary PCI. Widespread primary PCI-capable center, improved awareness about myocardial infarction and regional transfer system are essential to shorten patient delay.
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There is a broad differential for new-onset cardiac dysrhythmia, and the rapid identification of the underlying cause of these cardiac emergencies can be lifesaving. Identifying wall motion abnormalities on point-of-care ultrasound (POCUS) is not a core echocardiography application for Emergency Medicine (EM) physicians. However, ruling in a regional wall motion abnormality can expedite patient-centered care and assist the busy EM physician in high-risk cases.
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Background: Over the past few decades, left ventricular (LV) dysfunction in ST-segment elevation myocardial infarction (STEMI) patients has been the focus of research. Recently, co-occurring right ventricular (RV) dysfunction has received more attention in clinical practice. We aimed to assess RV function using cardiac magnetic resonance (CMR) imaging and identify factors that may contribute to RV dysfunction in STEMI patients. Methods: We retrospectively studied 189 patients with STEMI who underwent CMR 1-7 days after successful percutaneous coronary intervention (PCI). The ejection fraction (EF), wall thickening rate (WTR), peak radial strain (RS), circumferential strain (CS) and longitudinal strain (LS) of the LV, interventricular septum (IVS) and RV were measured with cine images. The location and extent of the infarct were determined using late gadolinium enhancement (LGE) imaging. The differences of function between STEMI patients with right ventricular ejection fraction (RVEF) <50% and those with RVEF ≥50% were compared using an independent-sample t-test. Linear regression analyses were used to determine independent predictors of RVEF. Results: RVEF <50% was observed in 32.28%% STEMI patients, who also demonstrated significantly lower left ventricular ejection fraction (LVEF), WTR, RS, CS, LS and larger infarct sizes than those with RVEF ≥50%. Patients with RVEF <50% also demonstrated a higher incidence of RV infarction, higher RV end-systolic volume (ESV) index, and lower RV RS and CS. Multivariable linear regression analysis revealed LV EF, IVS WTR and IVS RS as significant predictors for RVEF, while male gender, the culprit lesion in the right coronary artery (RCA), peak troponin were negative predictors for RVEF. Notably, peak troponin, LV EF, LV RS, LV CS, LV WTR, and IVS WTR demonstrated higher area under the curve (AUC) values for predicting RV dysfunction. Conclusions: RV dysfunction was detected in 32.28% of STEMI patients. Patients with acute STEMI and RVEF <50% had impaired LV and IVS functions. Systolic function of the LV and IVS, peak troponin, and culprit lesions in the RCA were independent predictors of RV dysfunction in STEMI patients.
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BACKGROUND: Evaluating high-sensitivity troponin I levels in emergency medicine is critical for diagnosing acute myocardial infarction (AMI). This study aims to evaluate the central laboratory versus bedside troponin I test in the emergency department of a tertiary care center. MATERIAL AND METHODS: This prospective observational study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India, from October to December 2023. Patient samples were analyzed in the central laboratory using the Dimension EXL 200 (Siemens® Healthcare Diagnostics Inc., Erlangen, Germany) as the gold standard test and through point-of-care testing using the TriageTrue® (Quidel Corporation, San Diego, CA) high-sensitivity troponin I kit, which was run on the Triage® MeterPro® device (Quidel Corporation, San Diego, CA). This device quantitatively determines troponin I in ethylenediaminetetraacetic acid-anticoagulated whole blood and plasma specimens. The results were compared. Statistical analysis was performed using SPSS version 18 (SPSS Inc., Chicago, IL). An unpaired t-test was performed to compare the difference in time taken using the two testing methods. RESULT: The mean time for obtaining troponin I results was substantially shorter with bedside testing (14.91 minutes, standard deviation (SD) = 0.5) than with laboratory testing (119.1 minutes, SD = 5.03). Statistical analysis revealed a significant difference (t = -172.36, p < 0.001). A chi-square test was conducted to assess the disparity between the two testing methods, yielding a chi-square value of 32.64 and a p value of 0.00001, indicating a significant difference between bedside testing and laboratory testing. CONCLUSION: The bedside high-sensitivity troponin I test offers a considerable advantage over laboratory testing regarding turnaround time within the emergency medicine department in India. This rapid diagnostic capability is crucial for timely management, which is beneficial for patients inconclusive of acute coronary syndrome-like non-ST segment elevation myocardial infarction (NSTEMI). It is also cost-effective. It also reduces the emergency boarding time and may reduce the number of unnecessary admissions in healthcare facilities.
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BACKGROUND: The effectiveness of complete revascularization is well established in patients with ST-segment elevation myocardial infarction (STEMI), but it is less investigated in those with non-ST-segment elevation myocardial infarction (NSTEMI). OBJECTIVES: This study aimed to assess whether complete revascularization, compared with culprit-only revascularization, was associated with consistent outcomes in older patients with STEMI and NSTEMI. METHODS: In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, 1,445 older patients with myocardial infarction (MI) were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs n = 253 complete) and NSTEMI (n = 469 culprit-only vs n = 467 complete). The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome included a composite of cardiovascular death or MI at 1 year. RESULTS: In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only vs 41 (16.2%) STEMI patients of the complete group (HR: 0.75; 95% CI: 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only vs 72 (15.4%) NSTEMI patients of the complete group (HR: 0.71; 95% CI: 0.53-0.97), with negative interaction testing (P for interaction, 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (P for interaction, 0.654). CONCLUSIONS: Physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI. (FIRE [Functional Assessment in Elderly MI Patients With Multivessel Disease]; NCT03772743).
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OBJECTIVE: To analyze the predictive value of the triglyceride-glucose (TyG) index and neutrophil-to-high-density lipoprotein ratio (NHR) for in-hospital major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI), and to establish an associated nomogram model. METHODS: In this retrospective study, we collected data from consecutive STEMI patients who underwent PCI from October 2019 to June 2023 at the Second People's Hospital of Hefei and the Second Affiliated Hospital of Anhui Medical University, as training and validation sets. Stepwise regression and multivariate logistic regression analysis were performed to screen independent risk factors, and a nomogram model was constructed and evaluated for its predictive efficacy. RESULTS: The TyG index, NHR, urea, diastolic blood pressure, hypertension, and left ventricular ejection fraction were independent risk factors for in-hospital MACE after PCI, and were used to construct the nomogram model. The C-index of the training and validation sets were 0.799 and 0.753, respectively, suggesting that the model discriminated well. Calibration and clinical decision curves also demonstrated that the nomogram model had good predictive power. CONCLUSION: In STEMI patients, increased TyG index and NHR were closely related to the occurrence of in-hospital MACE after PCI. Our constructed nomogram model has some value for predicting the occurrence of in-hospital MACE in STEMI patients.
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Glicemia , Lipoproteínas HDL , Neutrófilos , Nomogramas , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Triglicerídeos , Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Masculino , Feminino , Triglicerídeos/sangue , Pessoa de Meia-Idade , Estudos Retrospectivos , Lipoproteínas HDL/sangue , Idoso , Fatores de Risco , Neutrófilos/patologia , Glicemia/análise , Glicemia/metabolismo , PrognósticoRESUMO
BACKGROUND: Diabetes mellitus (DM) and coronary microvascular dysfunction (CMD) increase the risk of adverse cardiac events in patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study aimed to evaluate the combined risk estimates of DM and CMD, assessed by the angiography-derived index of microcirculatory resistance (angio-IMR), in patients with NSTEMI. METHODS: A total of 2212 patients with NSTEMI who underwent successful percutaneous coronary intervention (PCI) were retrospectively enrolled from three centers. The primary outcome was a composite of cardiac death or readmission for heart failure at a 2-year follow-up. RESULTS: Post-PCI angio-IMR did not significantly differ between the DM group and the non-DM group (20.13 [17.91-22.70] vs. 20.19 [18.14-22.77], P = 0.530). DM patients exhibited a notably higher risk of cardiac death or readmission for heart failure at 2 years compared to non-DM patients (9.5% vs. 5.4%, P < 0.001). NSTEMI patients with both DM and CMD experienced the highest cumulative incidence of cardiac death or readmission for heart failure at 2 years (24.0%, P < 0.001). The combination of DM and CMD in NSTEMI patients were identified as the most powerful independent predictor for cardiac death or readmission for heart failure at 2 years (adjusted HR: 7.894, [95% CI, 4.251-14.659], p < 0.001). CONCLUSIONS: In patients with NSTEMI, the combination of DM and CMD is an independent predictor of cardiac death or readmission for heart failure. Angio-IMR could be used as an additional evaluation tool for the management of NSTEMI patients with DM. TRIAL REGISTRATION: URL: https://www. CLINICALTRIALS: gov ; Unique identifier: NCT05696379.
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Angiografia Coronária , Circulação Coronária , Diabetes Mellitus , Microcirculação , Infarto do Miocárdio sem Supradesnível do Segmento ST , Readmissão do Paciente , Intervenção Coronária Percutânea , Valor Preditivo dos Testes , Resistência Vascular , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Idoso , Medição de Risco , Estudos Retrospectivos , Intervenção Coronária Percutânea/efeitos adversos , Fatores de Risco , Fatores de Tempo , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/diagnóstico , Resultado do Tratamento , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/epidemiologia , China/epidemiologiaRESUMO
BACKGROUND: Older people less frequently receive invasive coronary angiography (ICA) for NSTEMI than younger patients. We describe care, ICA data, and in-hospital and 30-day outcomes of NSTEMI by age in a contemporary and geographically diverse cohort. METHODS: Prospective cohort study including 2947 patients with NSTEMI from 287 centres in 59 countries, stratified by age (≥75 years, n = 761). Quality of care was evaluated based on 12 guideline-recommended care interventions, and data collected on ICA. Outcomes included in hospital acute heart failure, cardiogenic shock, repeat myocardial infarction, stroke/transient ischaemic attack, BARC Type ≥3 bleeding and death, as well as 30-day mortality. RESULTS: Patients aged ≥75 years, compared with younger patients, at presentation had a higher prevalence of comorbidities and oral anticoagulation prescription (22.4% vs 7.6%, p < 0.001). Older patients less frequently received ICA than younger patients (78.6% vs 90.6%, p < 0.001) with the recorded reason more often being advanced age, comorbidities or frailty. Of those who underwent ICA, older patients more frequently demonstrated 3-vessel, 4-vessel and/or left main stem coronary artery disease compared to younger patients (49.7% vs 34.1%, p < 0.001) but less frequently received revascularisation (63.6% vs 76.9%, p < 0.001). Older patients experienced higher rates of in-hospital acute heart failure (15.0% vs 8.4%, p < 0.001) and bleeding (2.8% vs 1.3%, p = 0.006), as well as in-hospital and 30-day mortality (3.4% vs 1.3%, p < 0.001; 4.8% vs 1.7%, p < 0.001; respectively), than younger patients. CONCLUSIONS: Patients aged ≥75 years with NSTEMI, compared with younger patients, less frequently received ICA and guideline-recommended care, and had worse short-term outcomes.
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Angiografia Coronária , Infarto do Miocárdio sem Supradesnível do Segmento ST , Sistema de Registros , Humanos , Idoso , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Masculino , Feminino , Estudos Prospectivos , Fatores Etários , Idoso de 80 Anos ou mais , Angiografia Coronária/estatística & dados numéricos , Mortalidade Hospitalar , Resultado do Tratamento , Pessoa de Meia-Idade , Comorbidade , Fatores de Risco , Intervenção Coronária Percutânea/estatística & dados numéricos , Intervenção Coronária Percutânea/mortalidade , Fatores de TempoRESUMO
This study explored 1-year follow-up of Parmaco-invasive strategy with half-dose recombinant human prourokinase (PHDP) in patients with acute ST-segment elevation myocardial infarction (STEMI). The follow-up endpoints were major adverse cardiovascular events (MACEs) occurring within 30 days and 1 year, as well as postoperative bleeding events. The study ultimately included 150 subjects, with 75 in the primary percutaneous coronary intervention (PPCI) group and 75 in the PHDP group. This study found that the PHDP group had a shorter FMC-reperfusion time (42.00 min vs 96.00 min, P < 0.001). During PCI, the PHDP group had a lower percutaneous transluminal coronary angioplasty (PTCA) (P = 0.021), intropin (P = 0.002) and tirofiban (P < 0.001) use. And the incidence of intraoperative arrhythmia, malignant arrhythmia, and slow flow/no-reflow was lower in the PHDP group (P < 0.001). At the 30-day follow-up, there was a significantly higher proportion of patients in the PPCI group who were readmitted due to unstable angina (P = 0.037). After 1 year of follow-up, there was no statistically significant difference in MACEs between the two groups (P = 0.500). The incidence of postoperative major bleeding, intracranial bleeding, and minor bleeding did not differ between the PHDP and PPCI groups (P > 0.05). The PHDP facilitates early treatment of infarct-related vessels, shortens FMC-reperfusion time, and does not increase the risk of MACEs.
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Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Masculino , Feminino , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Pessoa de Meia-Idade , Seguimentos , Idoso , Prognóstico , Intervenção Coronária Percutânea/métodos , Proteínas Recombinantes/uso terapêuticoRESUMO
BACKGROUND: The Smoking paradox has generated inconsistent findings concerning the clinical prognosis of acute ST-segment elevation myocardial infarction (STEMI) patients, while providing limited insights into coronary anatomy and function which are crucial prognostic factors. Therefore, this study aimed to further investigate the existence of smoking paradox in coronary anatomy and function. METHODS: This study divided STEMI patients into smokers and non-smokers. Quantitative coronary angiography, angiographyderived microcirculatory resistance (AMR) and quantitative flow ratio (QFR) were utilized to analyze coronary anatomy and function. These parameters were compared using multivariable analysis and propensity score matching. The clinical outcomes were evaluated using Kaplan-Meier curve and Cox regression. RESULTS: The study included 1258 patients, with 730 in non-smoker group and 528 in smoker group. Smokers were significantly younger, predominantly male, and had fewer comorbidities. Without adjusting for confounders, smokers exhibited larger lumen diameter [2.03(1.45-2.57) vs. 1.90(1.37-2.49), P = 0.033] and lower AMR [244(212-288) vs. 260(218-301), P = 0.006]. After matching and multivariate adjustment, smokers exhibited inversely smaller lumen diameter [1.97(1.38-2.50) vs. 2.15(1.63-2.60), P = 0.002] and higher incidence of coronary microvascular dysfunction [233(53.9%) vs. 190(43.6%), P = 0.002], but showed similar AMR and clinical outcomes compared to non-smokers. There was no difference in QFR between two groups. CONCLUSION: Smoking among STEMI patients undergoing pPCI was associated with smaller lumen diameter and higher occurrence of coronary microvascular dysfunction, although it had no further impact on clinical prognosis. The smoking paradox observed in coronary anatomy or function may be explained by younger age, gender, and lower prevalence of comorbidities.
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Angiografia Coronária , Circulação Coronária , Vasos Coronários , Microcirculação , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Fumantes , Fumar , Humanos , Masculino , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Feminino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Idoso , Fumar/efeitos adversos , Fumar/epidemiologia , Resultado do Tratamento , Fatores de Risco , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Medição de Risco , não Fumantes , Estudos Retrospectivos , Fatores de Tempo , Resistência VascularRESUMO
BACKGROUND: A growing population of patients with chronic kidney disease (CKD) presents with non-ST-segment-elevation myocardial infarction, although little is known about their longer-term mortality. METHODS AND RESULTS: Using the MINAP (Myocardial Ischaemia National Audit Project) registry, linked to Office for National Statistics mortality data, we analyzed 363 559 UK patients with non-ST-segment-elevation myocardial infarction, with or without CKD. Cox regression models were fitted, adjusting for baseline demographics. Compared with patients without CKD, patients with CKD were less frequently prescribed P2Y12 inhibitors (89% versus 86%, P<0.001) less likely to undergo invasive angiography (67% versus 41%, P<0.001) or percutaneous coronary intervention (41% versus 25%, P<0.001), and were less often referred to cardiac rehabilitation (80% versus 66%, P<0.001). Following non-ST-segment-elevation myocardial infarction, patients with CKD had higher risk of 30-day (adjusted hazard ratio [HR], 1.24 [95% CI, 1.20-1.29], 1-year 1.47 [95% CI, 1.44-1.51]) and 5-year mortality 1.55 (95% CI, 1.53-1.58) than patients without CKD (all P<0.001). Risk of mortality over the entire study period was highest in CKD Stage 5 (HR, 2.98 [95% CI, 2.87-3.10]), even after excluding mortality ≤30 days (HR, 3.03 [95% CI, 2.90-3.17]) (P<0.001). There was no significant difference in proportion of deaths attributable to cardiovascular disease at 30 days (CKD; 76% versus no CKD; 76%), or 1 -year (CKD; 62% versus no CKD; 62%). CONCLUSIONS: Patients with CKD were significantly less likely to receive invasive investigation or undergo percutaneous coronary intervention and had significantly higher risk of short- and longer-term mortality. Risk of mortality increased with reducing CKD stage. Cardiovascular disease was the main cause of mortality in patients with CKD, but at comparable rates to the general population with non-ST-segment-elevation myocardial infarction.
Assuntos
Infarto do Miocárdio sem Supradesnível do Segmento ST , Sistema de Registros , Insuficiência Renal Crônica , Humanos , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , Insuficiência Renal Crônica/complicações , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Reino Unido/epidemiologia , Fatores de Tempo , Intervenção Coronária Percutânea/estatística & dados numéricos , Intervenção Coronária Percutânea/mortalidade , Seguimentos , Fatores de Risco , Idoso de 80 Anos ou mais , Medição de Risco , Avaliação de Processos e Resultados em Cuidados de SaúdeRESUMO
The Dressler-de Winter sign is an electrocardiogram (ECG) pattern characterized by upsloping ST-segment depression in leads V1-V6 followed by tall, hyperacute T waves, typically indicating an occlusion of the left anterior descending artery (LAD). We present a case involving an inferoposterior ST-segment elevation myocardial infarction (STEMI) with a variant of the de Winter sign, a concept of ST-segment continuum in the precordial leads. Despite initial ECG findings suggesting right coronary artery (RCA) or left circumflex artery (LCX) involvement, coronary angiography confirmed occlusion of the wrap-around LAD distal to the first septal (S1) and diagonal branch (D1) and revealed a left dominant system accompanied by a small non-dominant RCA. This case highlights the diagnostic complexity in accurately localizing the culprit artery in STEMI cases exhibiting the de Winter sign. Understanding such ECG variants is crucial for analyzing the mechanisms of acute ischemia and ensuring accurate assessment of the culprit vessel for effective revascularization.
Assuntos
Angiografia Coronária , Eletrocardiografia , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Masculino , Diagnóstico Diferencial , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Clinical outcomes of patients presenting with STEMI are significantly improved by reducing time from vessel occlusion to coronary blood flow restoration. In an effort to improve outcomes, we developed a secure mobile application, STEMIcathAID, and designed a pilot project implementing the app into the workflow for STEMI patients transfer. The aim of the study is to assess the impact of the app on key metrics for STEMI transfer before (historic) and after app launch. METHODS: The pilot project included physicians, nurses and technicians from the Emergency Medicine and Nursing Departments at the referring center, the catheterization laboratory and transfer center. From July 2021 to February 2023, the referring center activated STEMIcathAID alarms in parallel with the previously established STEMI activation with traditional phone call to transfer center. RESULTS: One hundred eleven suspected STEMI calls were activated through the app with 66 accepted and 45 rejected cases; thirty-one STEMI cases with available device time were compared with 42 STEMIs activated through the traditional pathway before the app implementation. Median door-to-device time for STEMIcathAID-assisted transfer decreased from 106 to 86 min (p < 0.001). The significant improvement, 20 min (19%), of the key metric for interhospital transfer resulted in all STEMI cases meeting the AHA goal of door-to-device time ≤ 120 min. In addition, median door-in-door-out time at the referral hospital decreased from 56 to 50 min (p = 0.01). CONCLUSIONS: Implementation of a mobile app into STEMI workflow of a large urban healthcare system significantly improved the quality of care for transfer of STEMI patients. TRIAL REGISTRATION: AHA Get With The Guidelines-Coronary Artery Disease® (GWTG-CAD) registry is a national quality improvement program and is not subject to the institutional review board approval.