Feasibility and efficacy of delayed pharmacoinvasive therapy for STelevation myocardial infarction

BACKGROUND ST-elevation myocardial infarction(STEMI)refers to a clinical syndrome that features symptoms of myocardial ischemia with consequent ST-elevation on electrocardiography and an associated rise in cardiac biomarkers.Rapid restoration of brisk flow in the coronary vasculature is critical in reducing mortality and morbidity.In patients with STEMI who could not receive primary percutaneous coronary intervention(PCI)on time,pharmacoinvasive strategy(thrombolysis followed by timely PCI within 3-24 h of its initiation)is an effective option.AIM To analyze the role of delayed pharmacoinvasive strategy in the window period of 24-72 h after thrombolysis.METHODS This was a physician-initiated,single-center prospective registry between January 2017 and July 2017 which enrolled 337 acute STEMI patients with partially occluded coronary arteries.Patients received routine pharmacoinvasive therapy(PCI within 3-24 h of thrombolysis)in one group and delayed pharmacoinvasive therapy(PCI within 24-72 h of thrombolysis)in another group.The primary endpoint was major adverse cardiac and cerebrovascular events(MACCE)within 30 d of the procedure.The secondary endpoints included major bleeding as defined by Bleeding Academic Research Consortium classification,angina,and dyspnea within 30 d.RESULTS The mean age in the two groups was comparable(55.1±10.1 years vs 54.2±10.5 years,P=0.426).Diabetes was present among 20.2%and 22.1%of patients in the routine and delayed groups,respectively.Smoking rate was 54.6%and 55.8%in the routine and delayed groups,respectively.Thrombolysis was initiated within 6 h of onset of symptoms in both groups(P=0.125).The mean time from thrombolysis to PCI in the routine and delayed groups was 16.9±5.3 h and 44.1±14.7 h,respectively.No significant difference was found for the occurrence of measured clinical outcomes in the two groups within 30 d(8.7%vs 12.9%,P=0.152).Univariate analysis of demographic characteristics and risk factors for patients who reported MACCE in the two groups did not demonstrate any significant correlation.Secondary endpoints such as angina,dyspnea,and major bleeding were non-significantly different between the two groups.CONCLUSION Delayed PCI pharmacoinvasive strategy in a critical diseased but not completely occluded artery beyond 24 h in patients who have been timely thrombolyzed seems a reasonable strategy.

Study of coronary sinus anatomy during levophase of coronary angiography

BACKGROUND Coronary sinus(CS)imaging has recently gained importance due to increasing need for mapping and ablation of electrophysiological arrhythmias and left ventricular(LV)pacing during cardiac resynchronization therapy(CRT).Retrograde venogram is the current standard for imaging CS and its tributaries.AIM To evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT.METHODS In this prospective observational study,164 patients undergoing routine coronary angiography for various indications(Chronic stable angina-44.5%,acute coronary syndrome-39.5%,Dilated cardiomyopathy-11%,atypical chest pain-5%)were included.Venous phase(levophase)of left coronary injection was recorded in left anterior oblique-cranial and right anterior oblique-cranial views.Visibility of coronary veins,width and shape of CS ostium,angulations of proximal CS with body of CS were noted.Presence,size,take-off angle and tortuosity of posterolateral vein(PLV),anterior interventricular veins(AIV)and middle cardiac vein(MCV)were also noted.RESULTS During levophase,visibility grade(Muhlenbruch grade)for coronary veins was 3 in 74%and 2 in 26%of cases.Visibility of CS did not correlate with body mass index.The diameter of CS ostium was<10 mm,10-15 mm and>15 mm in 48%,42%and 10%of patients respectively.Proximal CS was tubular in 136(83%)patients and funnel-shaped in 28(17%)patients.Sharp take-off angulation between ostium and body of CS was seen in 16(10%)patients.Two or more PLV were present in 8 patients while PLV was absent in 52(32%)patients.Angle of take-off of PLV with body of CS was favourable(0°-45°)in 65(40%)patients.The angle was 45°-90°in 36 patients and difficult take-off angle(>90°)was seen in 8 patients.Length of PLV reached distal third of myocardium in 84 cases and middle third in 11 cases.There was no tortuosity in 79 cases,a single bend in 29 cases and more than 2 bends in 4 cases.Thirty nine(24%)patients had other veins supplying posterior/Lateral wall of LV.There was a single vein supplying lateral/posterior wall in 31(19%)patients.Diameter of MCV and AIV was significantly larger in patients with absent PLV as compared to patients with a PLV.CONCLUSION Levophase study of left coronary injection is effective in visualization of the CS in almost all patients undergoing coronary angiography and may be an effective alternative to retrograde venogram in patients with LV dysfunction or LBBB.