The impact of clinical syntax score on the immediate and six month clinical outcomes in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous intervention

In a substantial number of patients with acute ST-segment elevation myocardial infarction (STEMI), myocardial perfusion at the myocardial cellular level continues to be impaired despite achieving brisk antegrade flow in the infarct-related coronary artery by primary percutaneous intervention. This is attributable to embolisation of the coronary thrombus into the distal vasculature, producing microvascular plugging, vasospasm, interstitial oedema and cellular injury. There is consequently less salvage of infarct size, reduced left ventricular function and poorer clinical outcomes. Glycoprotein inhibitors are the most potent inhibitors of platelet aggregation and have been repeatedly shown to improve clinical outcomes in acute STEMI when administered intravenously. In recent years, randomised trials have demonstrated that glycoprotein inhibitors administered by the intracoronary route are safe and effective in reducing infarct size and providing better clinical outcomes than when given intravenously. Simultaneously, numerous randomised studies using adjunct manual thrombus extraction during primary percutaneous intervention in patients with acute STEMI have shown significantly better ST-segment resolution and myocardial blush grade, suggesting improved myocardial reperfusion, and, more importantly, significant one-year reductions in mortality. However, manual thrombus extraction cannot be used in all patients because there are occasions when the thrombus burden is too large to be aspirated completely or it is impossible to negotiate the thrombus extraction catheter beyond the occlusion. Similarly, glycoprotein inhibitors albeit delivered by the intracoronary route are unable to produce disaggregation of thrombus in all STEMI patients. A small pilot study involving 40 patients with acute STEMI demonstrated that the combination of intracoronary tirofiban and manual thrombus extraction is both safe and effective. However, there are no randomised data on the combined usage of intracoronary tirofiban and manual thrombus extraction in acute ST-elevation and, therefore, it is imperative that large, adequately powered, randomised studies are undertaken to study the synergistic effects of these two modalities. This article describes the various studies that have compared intracoronary glycoprotein inhibitors with the intravenous route and the rationale behind the advantages of manual thrombus extraction in the setting of acute STEMI.

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59 Prasugrel loading for patients with high bleeding risk presenting with ST-segment elevation myocardial infarction referred for primary percutaneous intervention – a retrospective analysis of bleeding and mortality

10.1136/heartjnl-2021-bcs.59 ◽

2021 ◽

Author(s):

Theofanis Nizamis ◽

Nikesh Jathanna ◽

Charlotte Leeson ◽

Sachin Jadhav

Keyword(s):

Myocardial Infarction ◽

Retrospective Analysis ◽

Bleeding Risk ◽

Percutaneous Intervention ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

High Bleeding Risk ◽

Primary Percutaneous Intervention

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Abstract 13993: Impact of Prasugrel Pretreatment and Timing of Coronary Artery Bypass Grafting on Clinical Outcomes of Patients With Non-ST-Segment Elevation Myocardial Infarction: From the Accoast Study

Circulation ◽

10.1161/circ.130.suppl_2.13993 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Dariusz Dudek ◽

Petr Widimsky ◽

Leonardo Bolognese ◽

Patrick Goldstein ◽

Christian Hamm ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Artery ◽

Clinical Outcomes ◽

Artery Bypass ◽

Bypass Grafting ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Cabg Patients ◽

The Impact

Objectives: We evaluated the impact of prasugrel pretreatment and timing of coronary artery bypass grafting (CABG) on clinical outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing CABG based on data from ACCOAST. Methods: We evaluated the impact of troponin, prasugrel pretreatment and CABG timing on clinical outcomes of NSTEMI patients undergoing CABG through 30 days from ACCOAST. Results: CABG patients versus PCI or medically managed patients were more often male, diabetic, had peripheral arterial disease and a higher GRACE score. By randomization assignment, 157 patients received a 30-mg loading-dose of prasugrel before CABG; 157 patients did not. CABG patients were grouped by tertiles of time from randomization to CABG; baseline characteristics in the Table. Patients in the lowest tertile had significantly more events (cardiovascular death, MI, stroke, urgent revascularization or glycoprotein IIb/IIIa bailout) and all TIMI major bleeds than those in the other 2 groups (p<0.045, p<0.002 respectively), but the patients in the higher 2 groups were not significantly different from each other. No difference was detected in all cause death among the 3 groups (p>0.39). A multivariate model evaluated 5 possible predictors of the composite endpoint of all cause death, MI, stroke and TIMI major bleeding. Time from randomization to CABG (HR 0.84 for each 1 hour of delay), left main disease presence (HR 1.76), and region of enrollment (Eastern Europe vs other, HR 3.83) were significant predictors but not prasugrel pretreatment or baseline troponin level ≥3xULN. Conclusions: In this group of high-risk patients presenting with NSTEMI, early surgical revascularization carried an increased risk of bleeding and ischemic complications, without impact on all-cause mortality. No impact of baseline troponin or prasugrel pretreatment (important factors influencing time of CABG) on clinical outcomes was confirmed.

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Abstract 14178: Characteristics and Outcomes of Young ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Intervention

Circulation ◽

10.1161/circ.142.suppl_3.14178 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Benjamin W Tung ◽

Zhe Yan Ng ◽

William Kristanto ◽

Kalyar W Saw ◽

winnie C sia ◽

...

Keyword(s):

Myocardial Infarction ◽

Older Patients ◽

Young Patients ◽

Percutaneous Intervention ◽

Old Patients ◽

Younger Patients ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Primary Percutaneous Intervention

Introduction: ST-segment elevation myocardial infarction (STEMI) is associated with significant morbidity and mortality leading to loss of productivity and productive life years, especially in younger patients. Understanding the characteristics of younger patients with STEMI and their outcomes could help focus public health efforts in STEMI prevention within a population. Aim: This study aims to compare the characteristics and outcomes of younger versus older patients with STEMI undergoing primary percutaneous intervention (PPCI). Methods: Data from the Coronary Care Unit database of the National University Hospital between July 2015 to June 2019 was reviewed. Patients were divided into Young (<50 years old) or Old (≥50 years old) groups. Results: Of the 1818 consecutive patients with STEMI and underwent PPCI, 465 (25.6%) were Young patients with mean age 43±4.9 years old as compared to Old patients with mean age 63.2±9.4 years old. Young patients were more likely to be male (94% vs. 85%, p<0.0001), current smokers (61.1% vs. 42.6%, p<0.0001), of Indian ethnicity (32% vs. 16.3%, p<0.0001), and had family history of myocardial infarction (MI) (18.1% vs. 9.5%, p<0.0001). Compared to Old patients, Young patients had better post-MI left ventricular ejection fraction (49.5±10.7 vs. 47.8±11.6, p=0.007) with fewer of them suffered from cardiogenic shock (7.1% vs. 13.2%, p<0.0001), and had lower mortality at one year (3.4% vs. 10.4%, p<0.0001). Although diabetes, hypertension and hyperlipidemia was less common among the Young patients when compared to the Old, the prevalence was high in the range of 28 to 38% (Table 1). Conclusions: A sizable proportion of STEMI patients are younger than 50 years old. The risk profile of these younger patients can be attributed to constitutional factors and smoking but other cardiovascular risk factors are also prevalent among them. Although mortality is lower among the younger than the older patients, it is not negligible.

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