293 Impact of metabolic syndrome on coronary microvascular dysfunction: a single-centre experience

Aims The purpose of this study was to evaluate whether microvascular dysfunction is more present in patients with metabolic syndrome (MetS) compared to diabetics and hypertensive patients with two angiographic imaging methods, to evaluate the degree of microcirculation dysfunction, the TIMI frame count and Myocardial Blush grade. Both techniques of rapid use and relatively cheap, and allow us to have a good degree of evaluation referred to the function of the coronary microcirculation. Methods and results The study included 445 patients allocated into three groups, 157 in the MetS group, 128 in the diabetics group, and 160 patients in the hypertensive group. All patients accessed to the emergency room for anginal chest pain, all were hospitalized in the cardiac intensive care unit from 2015 to 2020. Inclusion criteria were the presences of chest pain and/or their positive stress test, and epicardial coronary arteries free from stenosis at coronary angiography. We compared the results obtained from the angiographic techniques (TIMI Frame Count and Myocardial Blush Grade) in the two subgroups: MetS vs. hypertensive, and MetS vs. diabetics. In the first subgroup, we analyzed the TFCs of the three vessels in patients with hypertension and comparing them with patients with MetS, we observed that the latter have a worse perfusion condition: the three epicardial coronary vessels have a higher TFC than the hypertensive population (TFC LAD 33.1 ± 5.6 vs. 28.4 ± 5.6, P = 0.018), (TFC RCA 27.2 ± 5.2 vs. 23.1 ± 5.2, P = 0.014) (TFC CX 27.9 ± 5.4 vs. 26.9 ± 5.4, P = 0.03). That indicates slow flow in patients with MetS coronary microcirculation. Analyzing the MBG, however, in the three coronary vessels of patients with hypertension compared to patients with metabolic syndrome, no difference was found in terms of worsening of the coronary microcirculation. Finally comparing the indices that summarize the values of the individual arteries both for the TFC and MBG, was seen as the TMBS is reduced in both groups (7.1 ± 0.49 vs. 7.1 ± 0.6, P-value = 0.04). The TTFC is instead higher in patients with MetS (83.9 ± 5.8 vs. 77.8 ± 6.7, P-value =0.024). Then we performed the same type of comparison between MetS and type 2 diabetic subgroup, in this comparison we observed how by analyzing the TFCs of the three coronary vessels, MetS patients have a slower coronary flow than patients with type 2 diabetes mellitus (TFC LAD 33.1 ± 5.6 vs. 30.6 ± 6.2, P = 0.04), (TFC RCA 27.2 ± 5.2 vs. 25 ± 5.3, P = 0.02), (TFC CX 27.9 ± 5.4 vs. 27.2 ± 5.6, P = 0.05). Comparing MBG of the three coronary vessels instead, the flow is lower in diabetic patients TTFC was higher in patients with metabolic syndrome (83.9 ± 5.8 vs. 82.7 ± 8.6, P-value = 0.02). While TMBS was lower in diabetic patients than in patients with metabolic syndrome (7.1 ± 0.49 vs. 6.7 ± 0.74, P-value = 0.01). Conclusions This study shows that patients with MetS had a major coronary microvascular dysfunction using TFC imaging technique, analysis compared to diabetics or hypertensive patients, these differences resulted to be statistically significant. A clinical evaluation of this parameters using TFC such in this study, might give further information about (CMD) in this patients in order to act to develop the best treatment to this patients and to improve their clinical condition.

Delayed endovascular surgery in patients with acute ST-segment elevation myocardial infarction due to massive culprit arterial thrombosis in the prevention of slow/no-reflow phenomenon

Aim. To assess whether delayed coronary artery stenting (CAS) can reduce the slow/no-reflow incidence in patients with ST-segment elevation myocardial infarction (STEMI) and massive thrombosis (TTG ≥3) of the infarct-related coronary artery (IRCA) compared with immediate CAS within primary PCI.Material and methods. Out of 3651 primary PCIs performed for acute STEMI in the period from January 2016 to May 2020 at the Mytishchi City Clinical Hospital, the retrospective analysis included 105 patients with massive IRCA thrombosis (TTG ≥3). The patients were divided into two groups: first group (n=55) — delayed CAS, second group (n=50) — immediate CAS. In the immediate CAS group, the PCI procedure ended with routine stent implantation, and in the delayed CAS group, stent implantation was delayed for at least 5 days.Results. In the delayed CAS group in comparison with immediate one, the slow/no-reflow phenomenon developed much less frequently in the form of a significant increase in the prevalence of TIMI 3 flow, better myocardial perfusion of myocardial blush grade (MBG) 2-3 (81,8 vs 64%; odds ratio (OR) 2,53; p=0,039) and ST segment resolution ≥70% (87,3% vs 58%; OR 4,97; p=0,001).Conclusion. Delayed CAS in patients with STEMI with massive thrombosis (TTG ≥3) of IRCA reduces the risk of slow/no-reflow phenomenon and can be considered as a possible alternative treatment vs immediate CAS, provided that stable coronary flow is restored before TIMI 3.

Glycoprotein IIb/IIIa inhibitors in combination with thrombus aspiration with, or without, stent implantation in patients presenting with S-T elevation myocardial infarction and high thrombus burden

Funding Acknowledgements Type of funding sources: None. Background High thrombus burden is an independent risk factor for death and complications, including no reflow, during primary percutaneous coronary intervention (PCI) for S-T elevation myocardial infarction (STEMI). Purpose To investigate whether a strategy of thrombus aspiration in combination with glycoprotein IIb/IIIa inhibitors without stent implantation is associated with a reduced incidence of slow- or no-reflow, and other thrombotic complications compared with stenting in patients with high thrombus burden. Methods A total of 210 patients with STEMI and high thrombus burden (thrombolysis in myocardial infarction thrombus grade ≥3) treated with thrombus aspiration in combination with glycoprotein IIb/IIIa inhibitors with or without stent implantation. Patients were divided into 2 groups: non-stent PCI group (deferred stenting, n = 105) and stent PCI group (immediate stenting, n = 105). A new catheterisation and deferred stent implantation was performed 48 - 72 hours after primary PCI. The end points were a myocardial blush grade of 0 or 1 (defined as absent or minimal myocardial reperfusion, respectively) and the postprocedural frequencies of a TIMI flow grade of 3, complete resolution of ST-segment elevation immediately after primary PCI, target vessel revascularization, reinfarction, death and the combination of major adverse cardiac events by 30 days after randomisation. Results A myocardial blush grade of 0 or 1 occurred in 26.3% of the patients in the stent PCI group and in 17.1% of those in the non-stent PCI group (p < 0.05). Complete resolution of ST-segment elevation occurred in 86.6% and 78.2% of patients, respectively (p = 0.35). At 30 days, the rate of death in the stent PCI group and non-stent PCI group was 1.7% and 1.0%, respectively (p = 0.33) and the rate of adverse events was 12.1% and 2.2%, respectively (p < 0.01). Conclusions Thrombus aspiration, in combination with glycoprotein IIb/IIIa inhibitors without immediate stenting, is an applicable and effective method in a large majority of patients with myocardial infarction with ST-segment elevation and a high thrombus burden.

Relationship of serum vitamin D levels with coronary thrombus grade, TIMI flow, and myocardial blush grade in patients with acute ST-segment elevation myocardial infarction

Background Vitamin D deficiency is a prevalent condition that is found in about 30–50% of the general population, and it is increasing as a new risk factor for coronary artery disease. Our study aimed to evaluate the relationship of serum vitamin D levels with coronary thrombus burden, Thrombolysis In Myocardial Infarction flow grade, and myocardial blush grade in patients managed by primary percutaneous coronary intervention for their first acute ST-segment elevation myocardial infarction. Results Eighty patients were included in the study with their first acute ST-segment elevation myocardial infarction and were managed by primary percutaneous coronary intervention. According to the serum concentrations of vitamin D, the study population was divided into 2 groups: group A with abnormal vitamin D levels less than 30 ng/ml (50 patients) and group B with normal vitamin D levels equal to or more than 30 ng/ml (30 patients). Angiographic data was recorded before and after coronary intervention. On comparing thrombus grade and initial and post-procedural Thrombolysis In Myocardial Infarction flow between both groups of patients, there was no significant difference (p = 0.327, p = 0.692, p = 0.397). However, myocardial blush grade was better in patients with normal vitamin D levels (p = 0.029) without a significant correlation between vitamin D concentration values and myocardial blush grade (r = 0.164, p = 0.146). Conclusions Patients with first acute ST-segment elevation myocardial infarction and normal vitamin D levels undergoing primary percutaneous coronary intervention had better myocardial blush grade and more successful microvascular reperfusion in comparison with patients with abnormal vitamin D levels. There was no significant difference between the normal and abnormal vitamin D groups regarding the coronary thrombus grade and Thrombolysis In Myocardial Infarction flow.

Identification of the high-risk patient in primary percutaneous coronary intervention: development and validation of a novel predictive index

Background Primary percutaneous coronary intervention (PPCI) is the best treatment for patients with ST elevation myocardial infarction (STEMI). Several risk scores have been created to help risk-stratify these patients but few of these can be calculated in-lab, during the acute event. Development of a score that could be applied during PPCI could aid operators' decisions regarding adjunctive therapies and post-procedural surveillance which could improve patient outcomes. This study aimed to develop a simple, practical risk model that could be applied during PPCI to identify high-risk patients. Methods Demographic, clinical and outcome data were collected for all patients, as part of the HEAT-PPCI trial, who underwent PPCI for suspected STEMI between February 2012 and November 2013 at our hospital. Independent predictors of the composite outcome of 28-day mortality or severe impairment of LV function (ejection fraction ≤35%) were identified using multiple logistic regression. A risk model was fitted and internal validation was performed by bootstrapping. External validation was performed on a separate cohort of patients with STEMI. Results The derivation cohort included 1271 patients, with 131/1271 = 10.3% experiencing the composite outcome of 28-day mortality or poor LV function. Three variables were required to predict the outcome: age (OR:2.07, 95% CI 1.55 to 2.78), location of the culprit artery (OR:6.16, 95% CI 4.00 to 9.47), myocardial blush grade post-PPCI (OR:2.32, 95% CI 1.39 to 3.88). External validation was performed on 324 patients undergoing PPCI from a different centre. The model showed good discrimination on ROC-curve analysis (c statistic 0.79, 95% CI 0.75 to 0.83) and performed well on external validation (c statistic 0.87, 95% CI 0.72 to 0.95). Accuracy of the risk model on the validation data was improved by simple recalibration. The model was used to create a risk prediction chart that can be used in-lab during PPCI (Figure 1). Conclusions We have developed a risk model that accurately predicts 28-day mortality or poor LV function following STEMI using age, culprit location and myocardial blush grade. The model can assist operators in identifying high-risk patients during PPCI. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): National Health Service, UK

Do Myocardial Blush Grade Following Chronic Total Occlusion Recanalization Improve Clinical Outcome of Chronic Coronary Syndromes Patients?

Background : Myocardial blush grade (MBG) is an angiographic parameter to describe the adequacy of myocardial reperfusion. The correlation between myocardial blush and the clinical outcome following chronic total occlusion (CTO) recanalization is still unclear. Our study aimed to investigate the impact of myocardial blush after CTO recanalization on the clinical outcome of CCS patients. Design : A retrospective cohort study was conducted. Patients who underwent CTO recanalization were divided into two groups based on the myocardial blush. Patients were classified as having good myocardial blush (MBG category 2 to 3 or QUBE 0 to 10.2) and poor myocardial blush (MBG category 0 to 1 or QUBE 10.2 to 36.4). The outcome measured was the improvement of angina measured using the Seattle Angina Questionnaire (SAQ) and the reduction of antianginal drug regimens. Results : The follow-up period was ranging from 2 to 24 months following the CTO recanalization procedure. The SAQ for physical limitation (83.86 ± 16.11 vs. 77.92 ± 3.44; p = 0.247), angina frequency (85.27 ± 17.44 vs. 74.76 ± 22.05; p = 0.105), and quality of life (73.24 ± 3.41 vs. 72.82 ± 3.56; p = 0.932) between the two groups was not significantly different. Good myocardial blush was not correlated with the reduction of antianginal drug regimens (10 (52.6) vs. 8 (40); p = 0.639). Conclusion : Myocardial blush post-CTO recanalization was not associated with the improvement of angina symptoms and the reduction of antianginal drug regimens among patients with CCS.

Myocardial blush grade: a determinant of left ventricular ejection fraction and adverse outcomes in STEMI

Background and aims Despite restoration of blood flow, subtle microvascular obstruction can occur. This obstruction can be graded using myocardial blush grade. We aimed to investigate the role of myocardial blush grade in ejection fraction and adverse outcomes, after percutaneous intervention. Methods A prospective, observational study was conducted at our institute with a calculated sample size. Variables such as age, gender, and ejection fraction were noted before the intervention. The patients were followed for 3 months to determine the outcomes. The data was analyzed using IBM SPSS software version 26.0. P-value of less than 0.05 was considered significant for the statistical tests. Results There were 74 male and 36 female participants in the study. The mean age was 52.20 ± 10.02 years. The most common adverse outcome was heart failure (18%). There was a significant Pearson’s correlation between myocardial blush grade and improvement in ejection fraction (p < 0.05). Improvement in myocardial blush grade was significantly related to a decrease in adverse outcomes (p < 0.05). Regression analysis proved myocardial blush grade and diabetes status as independent predictors of percentage increase in ejection fraction (p < 0.05). Conclusion High myocardial blush grade is one of the independent predictors of better outcomes in ST-elevation myocardial infarction.

Assessment of Myocardial Perfusion by Angiographic Methods in Tortuous Coronary Arteries

The relationship between coronary tortuosity (CorT) and tissue-level myocardial perfusion is not clear. We investigated tissue perfusion in myocardial territories supplied by tortuous coronary arteries. Among patients who had undergone coronary angiography, patients with reported CorT, those with ≥1 coronary artery were included in the study group (100 patients). The control group included patients with normal coronary arteries (100 patients). Thrombolysis In Myocardial Infarction frame count (TFC) and myocardial blush grade (MBG) were calculated for each coronary artery. Mean TFC was significantly higher in tortuous right coronary artery (RCA), left anterior descending (LAD) artery, and circumflex (Cx) artery compared to their non-tortuous counterparts (28.81 ± 6.463 vs 21.94 ± 3.328, P = .009; 43.28 ± 5.698 vs 36.17 ± 3.875, P = .006; 29.35 ± 4.111 vs 23.821 ± 2.639; P < .001, respectively). Mean MBG was also significantly lower in tortuous RCA, LAD, and Cx, compared to their normal counterparts (2.78 ± 0.417 vs 2.98 ± 0.155, P < .001; 2.74 ± 0.483 vs 2.97 ± 0.164, P < .001; 2.92 ± 0.277 vs 2.99 ± 0.110, P < .001, respectively). For each tortuous coronary artery, TFC was similar for every MBG category. Tortuous coronary arteries have higher TFC and lower MBG, suggesting impaired epicardial and microvascular coronary flow, when compared to normal coronary arteries.

Impact of Postdilation on Intervention Success and Long-Term Major Adverse Cardiovascular Events (MACE) among Patients with Acute Coronary Syndromes

Postdilation is frequently used during coronary interventions to prevent stent malapposition. Currently there are contradictory findings regarding the benefits of postdilation for both intraprocedural and long-term outcomes. We evaluated the impact of postdilation among patients who presented with acute coronary syndromes (ACS) and underwent percutaneous coronary interventions (PCI). A total of 258 consecutive patients who presented with ACS and underwent PCI were included in the study. The patients were followed up for 25±1.7 months for the occurrence of major adverse cardiovascular events (MACE). During follow-up, 65 patients (25.2%) had MACE. Among patients without MACE, intracoronary nitrate infusion was less frequently used (P=0.005), myocardial blush grade was higher (P<0.001), and a drug-eluting stent was more frequently used (P=0.005). No significant differences were noted between groups regarding the predilation, recurrent dilation, postdilation, and other angiographic characteristics. In multivariate analysis, female sex (P=0.047), myocardial blush grade (P=0.038), previous coronary artery disease (P=0.030), and peak troponin level (P=0.002) were found to be predictors of MACE. In patients who were treated with PCI for ACS, performing postdilation did not predict final Thrombolysis in Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count, myocardial blush grade, or MACE.