Comparison of Intracoronary Versus Intravneous Tirofiban in Acute STEMI Patients Undergoing Primary PCI

Objective: This study aimed to investigate the effect of intracoronary tirofiban compared to intravenously administered tirofiban in acute ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI).Methods: This study included 180 patients who were admitted with the diagnosis of acute STEMI and undergoing primary PCI. Patients were randomized into an observation group (n = 90) and control group (n = 90). Both groups received typical treatments, such as aspirin and clopidogrel/ticagrelor. During the procedure, the observation and control groups were administered intracoronary (IC) or intravenous (IV) injections of tirofiban, respectively, followed by an intravenous infusion of tirofiban for 24 hours. Changes in thrombolysis in myocardial infarction (TIMI) flow grading, TIMI myocardial perfusion grade 3 (TMP grade 3), thrombus aspiration, brain natriuretic peptide (BNP) levels, creatine kinase peak and inflammatory factor levels, infarct size, resolution of the sum of ST‐segment elevation (Sum‐STR) two hours after the operation, and cardiac functional parameters were investigated before and/or after treatment and 6 months after discharge. The incidence of major adverse cardiovascular events (MACE) and adverse reactions (AEs) such as bleeding were compared between the two groups.Results: There were no statistically significant differences observed in the indices of BNP, creatine kinase peak, cardiac functional parameters, thrombus aspiration, or incidence of bleeding between the two groups before treatment. Following treatment, TIMI flow grading and TMP grade 3 were improved in the observation group that received intracoronary tirofiban compared to the control group (p = 0.022 and p = 0.014, respectively). Additionally, the Sum‐umi two hours after operation in the observation group was better than that in the control group (p = 0.029). The incidence of MACEs in patients given IC tirofiban administration was lower than that in those given IV tirofiban (p = 0.012). Furthermore, levels of glutamic oxaloacetictransaminase (AST), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and myocardial troponin I (TNI) in the observation group was significantly decreased compared to the control group after five days of treatment (p = 0.039, p = 0.040, p = 0.001, and p = 0.041, respectively). Functional heart parameters including CO and LVEF were significantly improved in the observation group 6 months after discharge.Conclusion: This study found that IC administration of tirofiban in patients with STEMI who underwent PPCI improved TIMI, TMP flow and cardiac function including CO and LVEF 6 months after discharge, and reduced CRP, ESR, and TNI. However, the incidence of bleeding between the two groups was comparable. These findings suggest that IC administration should be applied in certain acute STEMI patients.

Temporary rise in blood thrombogenicity in patients with acute myocardial infarction

Objective: Although blood thrombogenicity seems to be one of the determinant factors for the development of acute myocardial infarction (MI), it has not been dealt with in-depth. This study aimed to investigate blood thrombogenicity and its change in acute MI patients. Methods and Results: We designed a prospective, observational study that included 51 acute MI patients and 83 stable coronary artery disease (CAD) patients who underwent cardiac catheterization, comparing thrombogenicity of whole blood between: (1) acute MI patients and stable CAD patients; and (2) acute and chronic phase in MI patients. Blood thrombogenicity was evaluated by the Total Thrombus-Formation Analysis System (T-TAS) using the area under the flow pressure curve (AUC30) for the AR-chip. Acute MI patients had significantly higher AUC30 than stable CAD patients (median [interquartile range], 1771 [1585 - 1884] vs. 1677 [1527 - 1756], p = 0.010). Multivariate regression analysis identified acute MI with initial TIMI flow grade 0/1 as an independent determinant of high AUC30 (β = 0.211, p = 0.013). In acute MI patients, AUC30 decreased significantly from acute to chronic phase (1859 [1550 - 2008] to 1521 [1328 - 1745], p=0.001). Conclusion: Blood thrombogenicity was significantly higher in acute MI patients than in stable CAD patients. Acute MI with initial TIMI flow grade 0/1 was significantly associated with high blood thrombogenicity by multivariate analysis. In acute MI patients, blood thrombogenicity was temporarily higher in acute phase than in chronic phase.

The Effect of Periprocedural Clinical Factors Related to the Course of STEMI in Men and Women Based on the National Registry of Invasive Cardiology Procedures (ORPKI) between 2014 and 2019

Background: There are several sex-related differences in the course, management, and outcomes of ST-elevation myocardial infarction (STEMI). This study aimed to identify the risk factors that may affect the odds of procedure-related death in patients with STEMI. Methods: The observational cohort study group consisted of 118,601 participants recruited from the National Registry of Invasive Cardiology Procedures (ORPKI). Results: Procedure-related death occurred in 802 (1.0%) men and in 663 (1.7%) women. The odds of procedure-related death among women were significantly higher than among men (OR, 1.76; 95% CI, 1.59–1.95; p < 0.001). The probability of procedure-related mortality was highest in both men and women with cardiac arrest in the cath lab, critical stenosis of the left main coronary artery, and direct transfer to the cath lab. The factors that reduced the probability of procedure-related mortality in both men and women were thrombolysis in myocardial infarction (TIMI) flow grade and the use of P2Y12 inhibitors in the peri-infarct period. Psoriasis was associated with increased odds of procedure-related death among men, whereas cigarette smoking reduced the odds among women. Conclusions: Procedure-related deaths occurred more frequently in women than men with STEMI. Additional scrutiny needs to be undertaken to identify factors influencing survival regarding gender differences.

580 Percutaneous coronary intervention or medical therapy as initial management strategy of patients with spontaneous coronary artery dissections: insight from the multicentre, international dissezioni spontanee coronariche (disco) registry

Aims Whether patients with spontaneous coronary artery dissection (SCAD) should undergo an initial conservative management or immediate revascularization through percutaneous coronary intervention (PCI) remains debated. To investigate the frequency and predictors of choosing a strategy of immediate PCI for SCAD, and to compare the clinical outcomes of immediate PCI patients with those undergoing an initial strategy of medical management. Methods and results 369 patients enrolled in the multicentre international DIssezioni Spontanee COronariche (DISCO) registry between January 2009 and December 2020 were included. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction (MI) and any PCI. 240 (65%) patients underwent initial medical management, whereas 129 (35%) had immediate PCI. PCI patients presented more frequently with ST segment-elevation myocardial infarction (STEMI) (68.2% vs. 35%, P &lt; 0.001) and had higher frequency of proximal coronary segment SCAD (31.8% vs. 6.7%, P &lt; 0.001), Thrombolysis in Myocardial infarction (TIMI) flow grade 0–1 (54.3% vs. 20.4%, P &lt; 0.001) and multivessel SCAD (18.6% vs. 9.2%, P = 0.015), as well as a more severe diameter stenosis [99% (100–90) vs. 90% (99–75), P &lt; 0.001]. At multivariate logistic regression, STEMI at presentation (vs. NSTE-ACS, OR: 3.30 95% CI: 1.56–7.12, P = 0.002), proximal coronary segment involvement (OR: 5.43, 95% CI: 1.98–16.45, P = 0.002), TIMI flow grade 0–1 and 2 (respectively, vs. grade 3: OR: 3.22 95% CI: 1.08–9.96, P = 0.038; and OR: 3.98; 95% CI: 1.38–11.80, P = 0.009) and diameter stenosis (per 5% increase, OR: 1.13; 95% CI: 1.01–1.28, P = 0.037) were predictors of immediate PCI, whereas the angiographic subtype 2B predicted a conservative approach (OR: 0.25; 95% CI: 0.07–0.83, P = 0.026). The frequency of in-hospital major adverse cardiac events did not differ between medically and PCI-treated patients. At 2-year follow-up, there were no differences with respect to the composite of MACE (11.7% vs. 13.9%, P = 0.47) and the individual components of cardiovascular death (0.4% vs. 0.7%, P = 0.65), non-fatal MI (8.3% vs. 9.3%, P = 0.92), and any PCI (8.7% vs. 12.4%, P = 0.23). Conclusions The choice between an immediate medical or PCI management of SCAD is mostly driven by clinical presentation and procedural aspects. In the DISCO cohort, the primary treatment approach was not associated with the risk of short-to-midterm adverse events.

Post-streptokinase PCI in STEMI patients exceeding the 24-h guidelines

Background Due to delay in obtaining approval from insurance institution, performing PCI after successful reperfusion using streptokinase was postponed for ˃24 h-1 week. The study was conducted to investigate safety and efficacy of such delay in comparison to the ideal guidelines of PCI (≤ 24 h) in 129 STEMI patients received streptokinase followed by PCI. Patients were divided into two groups: (group 1 = 57; early PCI ≤ 24 h.) and (group 2 = 72; late PCI > 24 h.). Results Primary end point was death, congestive heart failure and reinfarction up to 30 days. Secondary end point was TIMI flow < G3, ischemic stroke, intracranial hemorrhage and non-intracranial bleeding. No statistical significant difference was found between both groups regarding LVEF, dimensions and myocardium wall preservation and incidence of complications and TIMI flow. No primary endpoints were detected. Five patients had secondary endpoints in early PCI and four in the late PCI. Suction device and IV Eptifibatide were used more in early PCI (p = 0.003). Conclusions The study suggests that relatively late PCI (> 24 h–1wk) after successful reperfusion using streptokinase in STEMI patients seems to be safe and effective in 30-day follow-up, provided that patients received DAPT and were subjected to close observation. The results seem safely applicable when we are forced to this choice; however lack of more investigations to this hypothesis is considered a limitation.

Vitamin D level predicts angiographic no-reflow phenomenon after percutaneous coronary intervention in patients with ST segment elevation myocardial infarction

Aim: No-reflow phenomenon (NRP) is an undesirable result of coronary interventions, and usually occurred during the primary percutaneous coronary intervention (PPCI). On the other hand, there is growing evidence of epidemiological studies suggest that serum 25 hydroxy-vitamin D (25(OH)D3) level is significantly associated with cardiovascular mortality and morbidity. Objective: To investigate whether there is a relationship between admission serum 25(OH)D3 levels and NRP in patients with ST elevation myocardial infarction (STEMI). Methods: This study consisted of 496 consecutive acute STEMI patients who underwent PPCI. After the restoration of antegrade flow, the patients were divided into the normal flow and no-reflow groups. No-reflow defined as; thrombosis in myocardial infarction (TIMI) flow grade ≤2, or a TIMI flow grade = 3 with a myocardial perfusion grade ≤1. Results: Angiographic no-reflow occurred 18.2% of all study patients. Serum 25(OH)D3 levels were significantly lower when compared with the normal flow group (14.6 ± 7.3 vs 22.6 ± 9.6 ng/ml; p < 0.001). 25(OH)D3 level was significantly negatively correlated with Neutrophil/lymphocyte (N/L) ratio. In multivariate analysis, 25(OH)D3 level on admission (OR: 0.738; 95% CI: 0.584–0.878; p = 0.001) was found an independent predictor of NRP together with N/L ratio, N-Terminal-proBNP, balloon pre dilatation and syntax score I. On receiver operating curve analysis (ROC), the cut-off value of admission 25(OH)D3 level was 10.5 ng/ml for the prediction of NRP with a sensitivity of 93% and specificity of 68%. The area under the ROC curve (AUC) was 0.772 (95% CI: 0.697–0.846; p < 0.001). Conclusion: We have shown that lower 25(OH)D3 level on admission is associated with higher NRP frequency and may be used as a predictor for NRP in STEMI patients undergoing PPCI.

Effect of high dose statin preloading on TIMI flow in patients presenting with ST-Elevation Myocardial Infarction undergoing Primary Percutaneous Coronary Intervention

Aim and objectives The aim of this study was to assess the impact of high intensity statins used prior to primary PCI in patients presenting with acute STEMI (ST-elevation Myocardial Infarction) on myocardial perfusion and in-hospital MACE (major adverse cardiac events). Patients and Methods The study included 170 patients who presented with acute STEMI to the cardiology department of Ain Shams university hospitals and underwent primary PCI (percutaneous coronary intervention). They were divided into two groups where the first group received high intensity statins (40-80mg of atorvastatin or 20-40mg of rosuvastatin) besides guideline recommended therapy before primary PCI and the 2nd group served as a control group and received guideline recommended therapy, and high intensity statins after going back to the coronary care unit after primary PCI. Post interventional thrombolysis in myocardial infarction (TIMI) flow grade and myocardial blush grade (MBG) were recorded and ST-segment resolution was measured. Results The majority of patients in both groups had the LAD as the culprit vessel for their presentation. In the control group there were 4 patients with TIMI I flow and MBG I, 13 with TIMI II flow and MBG II and 68 with TIMI III flow and MBG III. Meanwhile in the cases group there was 1 patient with TIMI I flow and MBG I, 3 with TIMI II flow and MBG II and 81 with TIMI III flow and MBG III. This difference was statistically significant with a P value of 0.010. There were 34 patients in the cases group who showed complete ST-segment resolution (40%) vs 19 patients (22.4%) in the control group which was statistically significant with a P value of 0.013. In addition, ejection fraction measured by M-mode had values of Mean+-SD of 45.91 ± 5.49 in cases group vs 43.01 ± 8.80 in control group which was statistically significant with a P value of 0.011. There was not a statistically significant difference between the two groups regarding in-hospital death of all causes and stroke after primary PCI. Conclusion High intensity statin loading before primary PCI resulted in improved post-procedural TIMI flow, MBG, complete ST-segment resolution and ejection fraction as measured by M-mode but did not decrease incidence of in-hospital MACE.

Comparison between preoperative loading dose with Ticagrelor and Clopidogrel on myocardial perfusion during intervention in patients with STsegment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Aim and Objectives The aim of this study is to compare between clopidogrel and ticagrelor loading doses used prior to primary PCI in patients presenting with acute STEMI (ST-elevation Myocardial Infarction) on myocardial perfusion and in-hospital MACE (major adverse cardiac events). Patients and Methods The study included 170 patients who presented with acute STEMI to the cardiology department of Ain Shams university hospitals and underwent primary PCI. They were divided into 2 groups where the1st group 85 patients received clopidogrel loading dose (600mg) and the 2nd group 85 patients received ticagrelor loading dose (180mg). Post interventional thrombolysis in myocardial infarction (TIMI) flow grade and myocardial blush grade (MBG) were recorded. Results The majority of patients in both groups had the LAD as the culprit vessel for their presentation (71.8% in the clopidogrel group and 50.6% in ticagrelor group). In the clopidogrel group there were 4 patients with TIMI I flow and MBG I, 13 with TIMI II flow and MBG II and 68 with TIMI III flow and MBG III. Meanwhile in the ticagrelor group there was 2 patients with TIMI I flow and MBG I, s with TIMI II flow and MBG II and 81 with TIMI III flow and MBG III. There was no statistical significance between the two groups regarding in-hospital death of all causes and stroke after primary PCI. Conclusion Ticagrelor loading before primary PCI resulted in improved TIMI flow, MBG but did not decrease incidence of in-hospital MACE.

Stenting deferral in primary percutaneous coronary intervention: exploring benefits and suitable interval in heavy thrombus burden

Background Deferred stenting, despite being successful in early studies, showed no benefit in recent trials. However, these trials were testing routine deferral; not in patients with heavy thrombus burden. Results This is a prospective, Randomized Clinical Trial that included 150 patients who presented with STEMI, patients were allocated into three equal groups after the coronary angiography ± primary intervention and before stenting of the culprit lesion; group (A) included 50 patients with early deferral of stenting, group (B) included 50 patients with late deferral and group (C) included 50 patients with immediate stenting. No-reflow was significantly higher in group C, while Final TIMI flow grade 3 and MBG grade 3 were significantly higher in group A and B than group C; p = 0.019 and < 0.001 respectively, with no significant difference between groups A and B, only the thrombus resolution in group B was significantly higher than group A; p < 0.001. Finally, 6-months, over-all MACE was significantly higher in group C (34.7% vs. 14.6% and 16.3%, p = 0.029). Conclusions Stent deferral was proved to be better than immediate stenting after recanalization of IRA, in achieving TIMI III flow, reducing risk of 6 months MACE, and restoration of myocardial function in a subset of STEMI patients presenting with large thrombus burden. While, no significant difference was found between both deferral times in final TIMI flow, or clinical outcomes.