Dataset Information

Outcomes of Patients Presenting With Clinical Indices of Spontaneous Reperfusion in ST-Elevation Acute Coronary Syndrome Undergoing Deferred Angiography.

ABSTRACT:

Background

Few data are available regarding the optimal management of ST-elevation myocardial infarction patients with clinically defined spontaneous reperfusion (SR). We report on the characteristics and outcomes of patients with SR in the primary percutaneous coronary intervention era, and assess whether immediate reperfusion can be deferred.

Methods and results

Data were drawn from a prospective nationwide survey, ACSIS (Acute Coronary Syndrome Israeli Survey). Definition of SR was predefined as both (1) ?70% reduction in ST-segment elevation on consecutive ECGs and (2) ?70% resolution of pain. Of 2361 consecutive ST-elevation-acute coronary syndrome patients in Killip class 1, 405 (17%) were not treated with primary reperfusion therapy because of SR. Intervention in SR patients was performed a median of 26 hours after admission. These patients were compared with the 1956 ST-elevation myocardial infarction patients who underwent primary reperfusion with a median door-to-balloon of 66 minutes (interquartile range 38-106). Baseline characteristics were similar except for slightly higher incidence of renal dysfunction and prior angina pectoris in SR patients. Time from symptom onset to medical contact was significantly greater in SR patients. Patients with SR had significantly less in-hospital heart failure (4% versus 11%) and cardiogenic shock (0% versus 2%) (P<0.01 for all). No significant differences were found in in-hospital mortality (1% versus 2%), 30-day major cardiac events (4% versus 4%), and mortality at 30 days (1% versus 2%) and 1 year (4% versus 4%).

Conclusions

Patients with clinically defined SR have a favorable prognosis. Deferring immediate intervention seems to be safe in patients with clinical indices of spontaneous reperfusion.

SUBMITTER: Fefer P

PROVIDER: S-EPMC5586258 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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Publications

Outcomes of Patients Presenting With Clinical Indices of Spontaneous Reperfusion in ST-Elevation Acute Coronary Syndrome Undergoing Deferred Angiography.

Fefer Paul P Beigel Roy R Atar Shaul S Aronson Doron D Pollak Arthur A Zahger Doron D Asher Elad E Iakobishvili Zaza Z Shlomo Nir N Alcalai Ronny R Einhorn-Cohen Michal M Segev Amit A Goldenberg Ilan I Matetzky Shlomi S

Journal of the American Heart Association 20170725 7

<h4>Background</h4>Few data are available regarding the optimal management of ST-elevation myocardial infarction patients with clinically defined spontaneous reperfusion (SR). We report on the characteristics and outcomes of patients with SR in the primary percutaneous coronary intervention era, and assess whether immediate reperfusion can be deferred.<h4>Methods and results</h4>Data were drawn from a prospective nationwide survey, ACSIS (Acute Coronary Syndrome Israeli Survey). Definition of SR ...[more]

PMID: 28743786

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Project description:Background Adenosine is used to treat no-reflow in the infarct-related artery (IRA) during ST-segment-elevation myocardial infarction intervention. However, the physiological effect of adenosine in the IRA is variable. Coronary steal-a reduction of blood flow to the distal coronary bed-can occur in response to adenosine and this is facilitated by collaterals. We investigated the effects of adenosine on coronary flow reserve (CFR) in patients presenting with ST-segment-elevation myocardial infarction to better understand the physiological mechanism underpinning the variable response to adenosine. Methods and Results Pressure-wire assessment of the IRA after percutaneous coronary intervention was performed in 93 patients presenting with ST-segment-elevation myocardial infarction to calculate index of microvascular resistance, CFR, and collateral flow index by pressure. Modified collateral Rentrop grade to the IRA was recorded, as was microvascular obstruction by cardiac magnetic resonance imaging. Coronary steal (CFR <0.9), no change in flow (CFR=0.9-1.1), and hyperemic flow (CFR >1.1) after adenosine occurred in 19 (20%), 15 (16%), and 59 (63%) patients, respectively. Patients with coronary steal had higher modified Rentrop score to the IRA (1 [0, 1.75] versus 0 [0, 1], P<0.001) and a higher collateral flow index by pressure (0.25±0.10 versus 0.15±0.10, P=0.004) than the hyperemic group. The coronary steal group also had significantly higher index of microvascular resistance (61.68 [28.13, 87.04] versus 23.93 [14.67, 37.00], P=0.006) and had more disease (stenosis >50%) in the donor arteries (52.63% versus 22.03%, P=0.02) than the hyperemic group. Conclusions Adenosine-induced coronary steal may be responsible for a reduction in coronary flow reserve in a proportion of patients presenting with ST-segment-elevation myocardial infarction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03145194. URL: https://www.isrctn.com; Unique identifier: ISRCTN3176727.

Project description:Background Intramyocardial edema and hemorrhage are key pathological mechanisms in the development of reperfusion-related microvascular damage in ST-segment-elevation myocardial infarction. These processes may be facilitated by abrupt restoration of intracoronary pressure and flow triggered by primary percutaneous coronary intervention. We investigated whether pressure-controlled reperfusion via gradual reopening of the infarct-related artery may limit microvascular injury in patients undergoing primary percutaneous coronary intervention. Methods and Results A total of 83 patients with ST-segment-elevation myocardial infarction were assessed for eligibility and 53 who did not meet inclusion criteria were excluded. The remaining 30 patients with totally occluded infarct-related artery were randomized to the pressure-controlled reperfusion with delayed stenting (PCRDS) group (n=15) or standard primary percutaneous coronary intervention with immediate stenting (IS) group (n=15) (intention-to-treat population). Data from 5 patients in each arm were unsuitable to be included in the final analysis. Finally, 20 patients undergoing primary percutaneous coronary intervention who were randomly assigned to either IS (n=10) or PCRDS (n=10) were included. In the PCRDS arm, a 1.5-mm balloon was used to achieve initial reperfusion with thrombolysis in myocardial infarction grade 3 flow and, subsequently, to control distal intracoronary pressure over a 30-minute monitoring period (MP) until stenting was performed. In both study groups, continuous assessment of coronary hemodynamics with intracoronary pressure and Doppler flow velocity was performed, with a final measurement of zero flow pressure (primary end point of the study) at the end of a 60-minute MP. There were no complications associated with IS or PCRDS. PCRDS effectively led to lower distal intracoronary pressures than IS over 30 minutes after reperfusion (71.2±9.37 mm Hg versus 90.13±12.09 mm Hg, P=0.001). Significant differences were noted between study arms in the microcirculatory response over MP. Microvascular perfusion progressively deteriorated in the IS group and at the end of MP, and hyperemic microvascular resistance was significantly higher in the IS arm as compared with the PCDRS arm (2.83±0.56 mm Hg.s.cm-1 versus 1.83±0.53 mm Hg.s.cm-1, P=0.001). The primary end point (zero flow pressure) was significantly lower in the PCRDS group than in the IS group (41.46±17.85 mm Hg versus 76.87±21.34 mm Hg, P=0.001). In the whole study group (n=20), reperfusion pressures measured at predefined stages in the early reperfusion period showed robust associations with zero flow pressure values measured at the end of the 1-hour MP (immediately after reperfusion: r=0.782, P<0.001; at the 10th minute: r=0.796, P<0.001; and at the 20th minute: r=0.702, P=0.001) and peak creatine kinase MB level (immediately after reperfusion: r=0.653, P=0.002; at the 10th minute: r=0.597, P=0.007; and at the 20th minute: r=0.538, P=0.017). Enzymatic myocardial infarction size was lower in the PCRDS group than in the IS group with peak troponin T (5395±2991 ng/mL versus 8874±1927 ng/mL, P=0.006) and creatine kinase MB (163.6±93.4 IU/L versus 542.2±227.4 IU/L, P<0.001). Conclusions In patients with ST-segment-elevation myocardial infarction, pressure-controlled reperfusion of the culprit vessel by means of gradual reopening of the occluded infarct-related artery (PCRDS) led to better-preserved coronary microvascular integrity and smaller myocardial infarction size, without an increase in procedural complications, compared with IS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02732080.

Project description:BackgroundAdmission hyperglycemia (AH) is a common finding in patients with acute coronary syndrome and has been reported to be associated with increased morbidity and mortality. Prior studies suggest that AH could be associated with reperfusion failure. We conducted a systematic review and meta-analysis to explore an association between AH and risk of reperfusion failure in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).MethodsTwo investigators searched the databases of MEDLINE and EMBASE from inception to February 2021. Study eligibility was independently determined by two investigators and needed to demonstrate association of AH and rate of reperfusion failure, or sufficient raw data to calculate the effect size. Participants were classified into two groups corresponding to their level of admission hyperglycemia. Group 1 was defined as an AH of ≥120-150 mg/dl, and group 2 as ≥150-200 mg/dl. Data from each study were combined using the random-effects model, the generic inverse-variance method of Der Simonian and Laird. The heterogeneity of effect size was quantified using the I2 statistic. A sensitivity analysis was performed by omitting one study at a time. Publication bias was assessed using a funnel plot and the Egger's test. All data analyses were performed using STATA SE version 14.2.ResultsA total of ten studies from 2008 to 2019 met eligibility criteria and were included in the final analysis. We found that AH is associated with increased risk of reperfusion failure in both group 1 (pooled OR=1.78, 95% CI: 1.35-2.33, I2=63.2%, P<0.001) and group 2 (pooled OR=1.44, 95% CI: 1.14-1.82, I2=57.1%, P<0.001). Sensitivity analysis showed that none of the results were significantly altered after removing one study at a time. In subgroup analysis of non-diabetic patients, we found that AH is also associated with increased risk of reperfusion failure in both group 1 (pooled OR=1.81, 95% CI: 1.29-2.54, P<0.001) and group 2 (pooled OR=1.61, 95% CI: 1.17-2.21, P<0.001). We did not perform a funnel plot or Egger's test as the number of available outcomes was insufficient to reject the assumption of funnel plot asymmetry.ConclusionsOur systematic review and meta-analysis demonstrated that AH is associated with increased risk of reperfusion failure in STEMI patients undergoing pPCI, in the non-diabetic population.

Project description:Background: Shenfu injection is a traditional Chinese medicine formulation that alleviates ischemia-reperfusion injury through multiple pharmacologic effects. However, no data are available regarding its efficacy in patients with myocardial infarction. We aimed to examine the effects of Shenfu injection on infarct size in patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods: From April 2016 to February 2018, 40 patients with first-time anterior STEMI undergoing primary PCI within 6 h of symptom onset were randomized 1:1 to intravenous Shenfu injection (80 ml Shenfu injection + 70 ml 5% glucose injection) or placebo (150 ml 5% glucose injection) before reperfusion. Treatment started before PCI and maintained for 5 days after PCI. The primary end point was infarct size assessed by CK-MB area under the curve (AUC) over 72 h and cardiac magnetic resonance (CMR) imaging 4 ± 1 days after PCI. Results: Infarct size by area under the curve for CK-MB over 72 h did not differ between the Shenfu injection and placebo groups (5602.5 [3539.4-7526.4] vs. 6403.2 [2234.4-8340.6] ng·h/ml, P = 0.82). Among 32 patients who underwent CMR Imaging, a nominal reduction in infarct size was observed in the Shenfu injection group compared with the placebo group (23.9 [15.2-28.5] % vs. 27 [21.9-31.9] %, P = 0.42). After excluding patients with no or minimal infarct, there was a trend toward reduction in infarct size in the Shenfu injection group (24.1 [20.3-29.3] % vs. 29.1 [24.5-32] %, P = 0.18). Incidence of adverse events was similar between the groups. Conclusions: This pilot study showed that the use of Shenfu injection was safe but did not reduce infarct size by CMR Imaging and CK-MB release kinetics in reperfused patients with STEMI. Larger studies (confining to patients with extensive infarct size) to evaluate the efficacy of Shenfu injection on reperfusion injury are warranted. Clinical Trail Registration: clinicaltrials.gov, identifier: NCT02709798.

Dataset Information

Outcomes of Patients Presenting With Clinical Indices of Spontaneous Reperfusion in ST-Elevation Acute Coronary Syndrome Undergoing Deferred Angiography.

Background

Methods and results

Conclusions

Publications

Outcomes of Patients Presenting With Clinical Indices of Spontaneous Reperfusion in ST-Elevation Acute Coronary Syndrome Undergoing Deferred Angiography.

Similar Datasets

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