Treatment of severe upper gastrointestinal bleeding caused by Mallory-Weiss syndrome after primary coronary intervention for acute inferior wall myocardial infarction: A case report

BACKGROUND Upper gastrointestinal bleeding(UGIB) after an acute myocardial infarction(AMI) is not an uncommon complication. Acute UGIB caused by Mallory-Weiss syndrome(MWS) is usually a dire situation with massive bleeding and hemodynamic instability. Acute UGIB caused by MWS after an AMI has not been previously reported.CASE SUMMARY A 57-year-old man with acute inferior wall ST elevation myocardial infarction underwent a primary coronary intervention of the acutely occluded right coronary artery. Six hours after the intervention, the patient had a severe UGIB,followed by vomiting. His hemoglobin level dropped from 15.3 g/d L to 9.7 g/d L. In addition to blood transfusion and a gastric acid inhibition treatment,early endoscopy was employed and MWS was diagnosed. Bleeding was stopped by endoscopic placement of titanium clips.CONCLUSION Bleeding complications after stent implantation can pose a dilemma. MWS is a rare but severe cause of acute UGIB after an AMI that requires an early endoscopic diagnosis and a hemoclip intervention to stop bleeding.

Outcomes after primary coronary intervention with drugeluting stent implantation in diabetic patients with acute ST elevation myocardial infarction

Background Drug-eluting stent （DES） has been used widely for the treatment of patients with acute coronary syndrome with or without diabetes mellitus during percutaneous coronary intervention （PCI）, but its long-term safety and efficacy in diabetic patients with acute ST elevation myocardial infarction （STEMI） remain uncertain. This study aimed to investigate the clinical outcomes after primary coronary intervention with DES implantation for diabetic patients with acute STEMI, compared with non-diabetic counterparts. Methods From December 2004 to March 2006, 56 consecutive diabetic patients （diabetic group） and 170 non-diabetic patients （non-diabetic group） with acute STEMI who underwent primary PCI with DES implantation in 3 hospitals were enrolled. Baseline clinical, angiographic, and procedural characteristics, as well as occurrence of major adverse cardiac event （MACE） including cardiac death, non-fatal recurrent myocardial infarction （re-MI） and target vessel revascularization （TVR） during hospitalization and one-year clinical follow-up were compared between the two groups. Results Patients in diabetic group were more hyperlipidemic （69.6% and 51.8%, P=-0.03） and had longer time delay from symptom onset to admission （（364±219） minutes and （309±223） minutes, P=-0.02） than those in non-diabetic group. The culprit vessel distribution, reference vessel diameter, and baseline TIMI flow grade were similar between the two groups, but multi-vessel disease was more common in diabetic than in non-diabetic group （82.1% and 51.2%, P〈0.001）. Despite similar TIMI flow grades between the two groups after stenting, the occurrence of TIMI myocardial perfusion grade （TMPG） 〉2 was lower in diabetic group （75.0% vs 88.8% in non-diabetic groups, P=-0.02）. The MACE rate was similar during hospitalization between the two groups （5.4% vs 3.5%, P=-0.72）, but it was significantly higher in diabetic group （16.1%） during one-year follow-up, as compared with non-diabetic group （6.5%, P=-0.03）. The cumulative one-year MACE-free survival rate was significantly lower in diabetic than in non-diabetic group （78.6% vs 90.0%, P=0.02）. Angiographic stent thrombosis occurred in 5.4% and 1.2% of the patients in diabetic and non-diabetic group, respectively （P=0.19）. All of these patients experienced non-fatal myocardial infarction. Conclusions Although the early clinical outcomes were similar in diabetic and non-diabetic patients with acute STEMI treated with DES implantation, the cumulative MACE-free survival at one-year follow-up was worse in diabetic than in non-diabetic patients. More effective diabetes-related managements may further improve the clinical outcomes of diabetic cohort suffering STEMI.

A randomized trail comparing primary percutaneous coronary intervention with a strategy of short-acting thrombolysis and immediate planned primary percutaneous coronary intervention in acute myocardial infarction

Objective This study was to evaluate the efficacy and safety of a short acting reduced dose fibrinolytic regimen to promote early infarct related artery (IRA) patency for acyute myocardial infarction (AMI) patients referred for percutaneous coronary intervention (PCI).Methods Following aspirin and heparin, 166 patients were randomized to a 50 mg bolus of recombinant tissue type plasminogen activator(rt PA) or to a same volume sodium chloride injection followed by immediate primary PCI. The end points included patency rates on catheterization laboratory (cath lab) arrival, revascularization results when PCI was performed, complication rates, left ventricular function and restored patency rate following PCI. Results Patency on cath lab arrival was 64% with rt PA (34% TIMI 3,30% TIMI 2), while 31% of placebo (13% TIMI 3, 18% TIMI 2). There was no difference in the restored TIMI 3 rates of IRA between the two groups (85% vs 87%). No difference were observed in stroke or major bleeding. Left ventricular function was similar in both groups (52±9% vs 50±8%), but left ventricular ejection fraction fraction (LVEF) was higher with patent IRA (TIMI 3) on cath lab arrival than that of others (56±12% vs 48±10%).Conclusions Strategy thrombolytic regimens were compatible with subsequent PCI lead to more frequenc early recanalization (before cath lab arrival), which facilitates greater left ventricular function preservation with no augmentation of adverse events.

A comparative study on transradial vs transfemoral artery access for primary percutaneous coronary intervention in patients with acute myocardial infarction

Objective Comparative study on the feasibility,safety and outcome of transradial artery and transfemoral artery access for primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction(AMI).Methods Two hundred and eight patients with AMI episoded within 12 hours, male 159, female 49, age 58.9 ±11.9 (34～88)years, were randomly divided into transradial artery access for primary PCI (TRA pPCI) group of 106 cases and transfemoral artery access for PCI (TFA pPCI) group of 102 cases during Sept, 2000 to Aug, 2002. The protocols of the manipulation duration and the effect for TRA pPCI and TFA pPCI procedures were respectively compared, including the time of transradial artery puncture and the rate of puncture success at first time ; the time of guiding catheter engaging into target coronary ostium; the rate of patence in infarct related artery (IRA); total duration of manipulation and the successful rate.The incidence of complications such as bleeding, vessel injury,thrombi and embolism as well as the average stay of hospitalization between two groups was compared. The status and the incidance of vessel spasm were observed and the effect of medicine administration to prevent from and relieve the vascular spasm was evaluated. The time of Allen’s test before and after TRA pPCI , the inner diameter and the peak of blood velocity of the right and left radial artery were investigated with color Doppler vessel echography as well as the complications of radial artery were followed up 1 month after TRA pPCI procedure. Results Two cases in every TRA pPCI and TFA pPCI groups were crossed over each other because procedure of the transradial or transfemoral access was failure. One handred and six vessels (48 vessels in LAD,22 vessels in LCX and 36 vessels in RCA) associated with 28 vessels of total occlusion in TRA pPCI group and 102 vessels (51 vessels in LAD,18 veesles in LCX and 33 vessels in RCA) with 24 vessels in total occlusion in TFA pPCI group were angioplasticized . The successful rates of the first time puncture in access artery, the re patence IRA and pPCI were similar in TRA pPCI and TFA pPCI groups ( 93.4% vs 96.1% ;100% vs 100%; 96.2% vs 97.1% , P >0.05 ). There were no significant diffierence in the average time of puncture time of access artery ,engaging in target vessels of guiding catheters and the total procedure of PCI between the two groups ( 1.3 ±0.3s vs 1.2 ±0.3s ; 6.0 ±1.6min vs 5.8 ±0.9min ; 49.2 ±24.1min vs 46.5 ± 26.4min , P >0.05 ). The access artery complications such as bleeding ,hematoma and embolism as well the veneous thrombosis in TFA pPCI group were much more than those in TRA pPCI group(p< 0.01 ). Although slight artery spasm of 4.7% cases in TRA pPCI group was happened during the procedure of PCI , the procedure had being continued after administration of medicine to release the spasm. The time of Allen’s test ,diameter and the systolic velocity of blood in daul radial arteries were no significant change before and after pPCI.Conclusions The duration and effect by TRA pPCI for AMI with stable hemodynamics was similar to TFA pPCI. The complications such as of bleeding,vessel injury, thrombi and embolism by TRA pPCI were few, and it was unnecessary to discontinue the anticoagulation medicine. TRA pPCI might be selected as a access vessel for pPCI in AMI patients with stable hemodynamics.

Effects of nicorandil on myocardial infarct size in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention:study design and protocol for the randomized controlled trial

Previous studies have shown that nicorandil has a protective effect on cardiomyocytes.However,there is no study to investigate whether perioperative intravenous nicorandil can further reduce the myocardial infarct size in patients with ST-segment elevation myocardial infarction(STEMI)compared to the current standard of percutaneous coronary intervention(PCI)regimen.The CHANGE(China-Administration of Nicorandil Group)study is a multicenter,prospective,randomized,double-blind and parallel-controlled clinical study of STEMI patients undergoing primary PCI in China,aiming to evaluate the efficacy and safety of intravenous nicorandil in ameliorating the myocardial infarct size in STEMI patients undergoing primary PCI and provide evidence-based support for myocardial protection strategies of STEMI patients.

Effectiveness and feasibility of transradial approaches for primary percutaneous coronary intervention in patients with acute myocardial infarction

Objective： To evaluate the efficacy and feasibility of the transradial approach for primary percutaneous coronary intervention （PCI） in patients with acute myocardial infarction（AMI）. Methods： 195 patients with acute myocardial infarction were randomly divided into two groups according to the different PCI operation pathways. 105 cases were assigned to the transfemoral artery group and 90 cases to the transradial artery group. We analyzed the data from the two groups, including the achievement ratio of paracentesis, cannulation time, the time from local anesthesia to the first time balloon inflation, the time of the total procedure, achievement ratio of PCI, incidence rate of vascular complications, total duration of hospitalization, and the six-month follow-up results in both groups. Results： Our results showed that the achier ement ratio of arteriopuncture, cannulafion time and the time from local anesthesia to the first time balloon inflation in the transradial and transfemoral groups were 98.9% vs. 100%, 3.15 ± 1.56min vs. 2.86 ± 0.97 min, and 18.56 ± 4.37 min vs. 17.75 ± 3.21 min, respectively. These differences between the two groups were not statistically significant. The total operating time was 29.75 ± 4.38 rain for the transradial group and 27.89 ± 3.95 min（P 〈 0.05） for the transfemoral group. The operation achievement ratio in the transradial group was 96.7%, and 96.2% in the transfemoral group. The incidence of puncture point complications was 2.2% in the transradial group and 11.4% in the transfemoral group, and this difference was significant. The duration of hospitalization was 10.56 ± 2.85 days for the transradial group and 13.78 ± 3.15 days（P 〈 0.05） for the transfemoral group. At the six-month follow-up, the rate of survival without cardiac event was 86.1% vs. 86.4% respectively in the transradial and transfemoral groups（P 〉 0.05）. Conclusion： The transradial approach was as effective as the transfemoral approach, and there were fewer puncture point complications as well as a shorter span of hospitalization in the transradial group. PCI via the transradial approach is safe, effective and feasible in patients with AMI.

Development of Primary Percutaneous Coronary Intervention as a National Reperfusion Strategy for Patients with ST-Elevation Myocardial Infarction and Assessment of Its Use in Egypt

Objective:Early treatment of acute ischemia of the heart by performing immediate percutaneous coronary intervention(PCI)to restore blood fl ow in patients with the clinical presentation of an acute coronary syndrome and more specifi cally with ST-elevation myocardial infarction(STEMI)can save lives.This study aims to identify the mean time(door to balloon time and fi rst contact to balloon time)to primary PCI for STEMI patients and to assess the percentage of primary PCI and its success rate in Egypt.Methods:A registry study of patients presenting to cardiac centers in Egypt was designed,where patients’basic characteristics,the treatment strategy,and the door to balloon time and the fi rst contact to balloon time were assessed.Results:One thousand six hundred fi fty STEMI patients with a mean age of 57 years were included in the study.Immediate transfer for primary PCI was the most used treatment strategy,representing 74.6%of all treatment strategies used.The door to balloon time and the fi rst contact to balloon time were 50 and 60 minutes,respectively,with a primary PCI success rate of 65.1%.Conclusion:The registry study results showed a marked improvement by implementation of the best treatment strategy with respect to the time factor to achieve a better outcome for STEMI patients in Egypt.

Staged Revascularization for Chronic Total Occlusion in the Non-IRA in Patients with ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention:An Updated Systematic Review and Meta-analysis

Objectives:Meta-analysis was performed to evaluate the effect of staged revascularization with concomitant chronic total occlusion(CTO)in the non-infarct-associated artery(non-IRA)in patients with ST-segment elevation myocardial infarction(STEMI)treated with primary percutaneous coronary intervention(p-PCI).Methods:Various electronic databases were searched for studies published from inception to June,2021.The primary endpoint was all-cause death,and the secondary endpoint was a composite of major adverse cardiac events(MACEs).Odds ratios(ORs)were pooled with 95%confidence intervals(CIs)for dichotomous data.Results:Seven studies involving 1540 participants were included in thefinal analysis.Pooled analyses revealed that patients with successful staged revascularization for CTO in non-IRA with STEMI treated with p-PCI had overall lower all-cause death compared with the occluded CTO group(OR,0.46;95%CI,0.23–0.95),cardiac death(OR,0.43;95%CI,0.20–0.91),MACEs(OR,0.47;95%CI,0.32–0.69)and heart failure(OR,0.57;95%CI,0.37–0.89)com-pared with the occluded CTO group.No significant differences were observed between groups regarding myocardial infarction and repeated revascularization.Conclusions:Successful revascularization of CTO in the non-IRA was associated with better outcomes in patients with STEMI treated with p-PCI.

The clinical relationship between corrected TIMI frame count and prognosis for patients with ST-elevation myocardial infarction after primary coronary intervention

Background Corrected thrombolysis in myocardial infarction(TIMI)frame count(CTFC)was a simple and sensitive prognostic method that could reflect the perfusion status.Contemporary data on the relationship between CTFC and the prognosis for patients with ST-elevation myocardial infarction are not available.Methods Between January 2013 and December 2019,183 STEMI patients who attended in our center were retrospectively analyzed.All of the patients underwent primary percutaneous coronary intervention(PCI)and were with final TIMI grade 3 flow.Those patients were divided into high CTFC group(CTFC≥23 frames,n=76)and low CTFC group(CTFC<23 frames,n=107).The primary endpoint was the incidence of major adverse cardiovascular events(MACEs)after 12 months.Univariate and multivariate cox regression analysis was performed to figure out prognostic factors.Results A total of 183 individuals were included in this study.MACE rate was significantly higher in those patients with high CTFC(32.9%vs.15.7%,P=0.012),especially the revascularization rate(18.4%vs.2.8%,P=0.012).Multivariate Cox regression analysis showed that CTFC was the independent predictors of worse prognosis[risk ratio(RR):0.75,95%confidence interval(CI)0.67-0.82,P<0.001].Conclusions CTFC is feasible to identify the high-risk group after primary PCI for STEMI patients.High CTFC was associated with poor short-term clinical outcome.[S Chin J Cardiol 2021;22(1):7-12]

Barriers to the Implementation of Primary PCI in the Management of STEMI in Egypt

Introduction:Evidence-based guidelines recommend primary percutaneous coronary intervention(PPCI)be the mainstay reperfusion strategy for the treatment of ST-segment elevation myocardial infarction(STEMI)if it is per-formed in the proper time window.However,the Egyptian health care system is still struggling to provide such an important service.The aim of the present study,through a quantitative questionnaire,is to explore the current practice of STEMI management in Egypt,and to identify the barriers,opportunities,and potential areas for improvement.Methods and Results:The questionnaire was conducted in Egypt via face-to-face qualitative in-depth interviews with cardiologists from 14 PPCI-capable hospitals and 26 non-PPCI-capable hospitals.Participants were selected in view of their experience and knowledge.The study identifi ed potential barriers to the implementation of PPCI among STEMI patients in Egypt.These barriers included the prehospital patient delay and emergency medical service delay,delay in the emergency department and delay in patient transfer to the CCU,unavailable equipment,catheterization laboratory activation delay,lack of trained interventional cardiologists,lack of regional STEMI networks and hospital policies,and insuffi cient ICU beds.Conclusion:Limited resources and health care system inadequacies have led to potential barriers that prevent sub-optimal implementation of PPCI in Egypt.Efforts from all health care providers should be directed to overcome these identifi ed barriers.

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.

Randomized comparison of intracoronary tirofiban versus urokinase as an adjunct to primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction： results of the ICTUS-AMI trial

Background No randomized trial has been performed to compare the efficacy of an intracoronary bolus of tirofiban versus urokinase during primary percutaneous coronary intervention （PCI）.We investigated whether the effects of adjunctive therapy with an intracoronary bolus of urokinase was noninferior to the effects of an intracoronary bolus of tirofiban in patients with ST-elevation myocardial infarction （STEMI） undergoing PCI.Methods A total of 490 patients with acute STEMI undergoing primary PCI were randomized to an intracoronary bolus of tirofiban （10 μg/kg; n=247） or urokinase （250 kU/20 ml; n=243）.Serum levels of P-selectin,von Willebrand factor （vWF）,CD40 ligand （CD40L）,and serum amyloid A （SAA） in the coronary sinus were measured before and after intracoronary drug administration.The primary endpoint was the rate of complete （＞70％） ST-segment resolution （STR） at 90 minutes after intervention,and the noninferiority margin was set to 15％.Results In the intention-to-treat analysis,complete STR was achieved in 54.4％ of patients treated with an intracoronary bolus of urokinase and in 60.6％ of those treated with an intracoronary bolus of tirofiban （adjusted difference：-7.0％;95％ confidence interval：-15.7％ to 1.8％）.The corrected TIMI frame count of the infarct-related artery was lower,left ventricular ejection fraction was higher,and the 6-month major adverse cardiac event-free survival tended to be better in the intracoronary tirofiban group.An intracoronary bolus of tirofiban resulted in lower levels of P-selectin,vWF,CD40L,and SAA in the coronary sinus compared with an intracoronary bolus of urokinase after primary PCI （P＜0.05）.Conclusions An intracoronary bolus of urokinase as an adjunct to primary PCI for acute STEMI is not equally effective to an intracoronary bolus of tirofiban with respect to improvement in myocardial reperfusion assessed by STR.This may be caused by less reduction in coronary circulatory platelet activation and inflammation.

Association of neutrophil/lymphocyte ratio with long-term mortality after ST elevation myocardial infarction treated with primary percutaneous coronary intervention

Background Primary percutaneous coronary interventions （PCI） have been proposed as a novel superior management strategy in patients with ST elevation myocardial infarction （STEMI）. This study tested the hypothesis that in the acute phase of myocardial infarction with ST-segment elevation, the neutrophil/lymphocyte （N/L） ratio is a predictor of long-term prognosis.Methods We analyzed 551 consecutive STEMI patients treated with primary PCl at a single university center. Patients were stratified according to quartiles of the mean neutrophil/lymphocyte ratio.Results Kaplan-Meier survival analysis showed a cumulative eight-year survival of 94.2% in the first quartile, 92.0% in the second quartile, 91.3% in the third quartile, and 75.4% in the fourth quartile （P ＜0.001 by log rank）. Relative to patients in the other three lower N/L ratio quartiles, patients in the highest quartile were more than four times more likely to die during hospitalization （P ＜0.001） and during long-term follow-up （P ＜0.001）. By multivariate Cox regression analysis including baseline demographic, clinical, and angiographic covariables, the N/L ratio in the highest quartile remained an independent predictor of mortality （hazard ratio 2.38, 95% confidence interval （CI） 1.42 to 3.98; P=0.001）.Conclusion The neutrophil/lymphocyte ratio is a strong independent predictor of long-term mortality after ST elevation myocardial infarction treated with very early revascularization.

Thorombolytic therapy with rescue percutaneous coronary intervention versus primary percutaneous coronary intervention in patients with acute myocardial infarction： a multicenter randomized clinical trial

Background Although thrombolytic therapy with rescue percutaneous coronary intervention （PCI） is a common treatment strategy for ST-segment elevation acute myocardial infarction （STEMI）, scant data are available on its efficacy relative to primary PCI, and comparison was therefore the aim of this study. Methods This multicenter, open-label, randomized, parallel trial was conducted in 12 hospitals on patients （age 〈70 years） with STEMI who presented within 12 hours of symptom onset （mean interval 〉3 hours）. Patients were randomized to three groups： primary PCI group （n=101）; recombinant staphylokinase （r-Sak） group （n=-104）; and recombinant tissue-type plasminogen activator （rt-PA） group （n=-106）. For all patients allocated to the thrombolytic therapy arm, coronary angiography was performed at 90 minutes after drug therapy to confirm infarct-related artery （IRA） patency; rescue PCI was performed in cases with TIMI flow grade 〈2. Bare-metal stent implantation was planned for all patients. Results After randomization it required an average of 113.4 minutes to start thrombolytic therapy （door-to-needle time）and 141.2 minutes to perform first balloon inflation in the IRA （door to balloon time）. Rates of IRA patency （TIMI flow grade 2 or 3） and TIMI flow grade 3 were significantly lower in the thrombolysis group at 90 minutes after drug therapy than in the primary PCI group at the end of the procedure （70.5% vs. 98.0%, P 〈0.0001, and 53.0% vs. 85.9%, P 〈0.0001, respectively）. Rescue PCI with stenting was performed in 117 patients （55.7%） in the thrombolytic therapy arm. Rates of patency and TIMI flow grade 3 were still significantly lower in the rescue PCI than in the primary PCI group （88.9% vs. 97.9%, P=-0.0222, and 68.4% vs. 85.0%, P=0.0190, respectively）. At 30 days post-therapy, mortality rate was significantly higher in the thrombolysis combined with rescue PCI group than in primary PCI group （7.1% vs. 0, P=0.0034）. Rates of death/MI and bleeding complications were significantly higher in the thrombolysis with rescue PCI group than in the primary PCI group （10.0% vs. 1.0%, P=-0.0380, and 28.10% vs. 8.91%, P=-0.O001, respectively）. Conclusions Thrombolytic therapy with rescue PCI was associated with significantly lower rates of coronary patency and TIMI flow grade 3, but with significantly higher rates of mortality, death/MI and hemorrhagic complications at 30 days, as compared with primary PCI in this group of Chinese STEMI patients with late presentation and delayed treatments.

Long-term Outcomes of Primary Percutaneous Coronary Intervention with Second-generation Drug-eluting Stents in ST-elevation Myocardial Infarction Patients Caused by Very Late Stent Thrombosis

Background： The ST-segment elevation myocardial inthrction （STEMI） patients due to stent thrombosis （ST） remain a therapeutic challenge for a clinician. Till date, very few researches have been conducted regarding the safety and effectiveness of primary percutaneous coronary intervention （PCI） with second-generation drug-eluting stents （DES） for STEMI caused by very late ST （VLST）. This retrospective study evaluated the safety, efficacy, and outcomes of primary PCI with second-generation DES for STEM1 due to VLST compared with primary PCI for STEM1 due to de novo lesion. Methods： Between January 2007 and December 2013, STEMI patients with primary PCI in Fuwai Hospital had only second-generation DES implanted for de novo lesion （558 patients） and VLST （50 patients） were included in this retrospective study. The primary end points included cardiac death and reinfarction. The secondary end points included cardiac death, reinfarction, and target lesion revascularization. Continuous variables were expressed as mean （standard deviation） or median （interquartile range） and compared by Student＇s t-test or Mann-Whitney U-test as appropriate. Categorical variables were expressed as counts and percentages, and comparison of these variables was performed with Chi-square or Fisher＇s exact test. A two-tailed value of P 〈 0.05 was considered statistically significant for all comparisons. Statistical analyses were performed by SAS software （version 9.4, SAS Institute Inc., Cary, USA） for Windows. Results： In-hospital primary end point and the secondary end point were no significant differences between two groups （P = 1.000 and P = 1.000, respectively）. No significant differences between two groups were observed according to the long-term primary end point and the secondary end point. Kaplan-Meier survival curves showed no significant difference between the two groups in the primary end point and the secondary end point at 2 years （P- 0.340 and P = 0,243, respectively）. According to Cox analysis, female, intra-aortic balloon pump support, and postprocedural thrombolysis in myocardial infarction flow 3 were found to be independent predictors fbr long-term follow-up. Conclusion： Primary PCI with second-generation DES is a reasonable choice for STEMI patients caused by VLST.

Direct intracoronary delivery of tirofiban during primary percutaneous coronary intervention for ST-elevation myocardial infarction

ST-segment elevation myocardial infarction （STEMI） is usually caused by acute occlusion of an infarct-related coronary artery （IRA）, resulting from rupture or erosion of an atherosclerotic plaque and subsequent platelet aggregation and thrombosis.l3 Prompt reperfusion is the key aspect of the optimal management,.7 and timely expert primary percutaneous coronary intervention （PCI） becomes the best reperfusion strategy with respect to improvement in survival and reduction of combined clinical endpoints in the treatment of STEMI.

Impact of primary percutaneous coronary intervention on blood perfusion in nonculprit artery in patients with anterior ST elevation myocardial infarction

Background Recent studies have demonstrated that epicardial flow in nonculprit arteries, which has been assumed to be normal, was slowed in the setting of ST-elevation myocardial infarction （STEMI）. However, the impact of primary percutaneous coronary intervention （PCI） on blood perfusion in nonculprit arteries in patients with STEMI has not been clarified. The purpose of this study was to investigate the impact of primary PCI on blood perfusion in nonculprit arteries in patients with STEMI and correlated clinical factors. Methods A total of 117 patients with anterior wall STEMI, the culprit artery being the left anterior descending artery （LAD）, undergoing primary PCI （the study group） and 100 patients with normal coronary angiography （the control group） were enrolled. To observe the differences of corrected TIMI frame count （cTFC） and myocardial blush grade （MBG） before and after primary PCI in both culprit and nonculprit arteries, the left circumflex coronary artery （LCX）, cTFC and MBG in the LAD and LCX were measured in the study group and control group. The study group was divided into three groups; refiow in the culprit artery group （the R group）, no reflow in culprit artery group （the NR group）, and no reflow in both the culprit artery and nonculprit artery group （the NRB group） according to MBG grade. The level of serum C-reactive protein （CRP）, catecholamine, and fibroblast growth factor-21 （FGF21）were assayed. The clinical and angiographic characteristics were also analyzed. Results cTFC （28.1±24.3 vs. 20.3±19.3, P 〈0.05） and MBG in the LCX were different in the study group compared to the control group before primary PCI. cTFC （25.2±22.3 vs. 28.1±24.3, P 〈0.05） and the MBG level in the LCX were improved after successful primary PCI, but were not recovered to the normal level. Patients with no reflow in the culprit artery had a higher incidence of no-reflow in the nonculprit artery （78% vs. 19%, P 〈0.0001）, and the levels of CRP （（3.29±1.31） mg/dl vs. （2.51±1.14） mg/dl vs. （2.93±1.07） mg/dl, P 〈0.05, respectively）, catecholamine （（epinephrine （693.48±89.78） pg/ml vs. （398.12±93.28） pg/ml vs. （562.54±96.22） pg/ml, P 〈0.0001, respectively）, and norepinephrine （（7012.43±932.47） pg/ml vs. （4012.34±814.16） pg/ml vs. （5549.03＋912.65） pg/ml, P 〈0.0001, respectively））in the NRB group were higher than those in the R group and NR group. The level of FGF21 （（0.299±0.093） ng/ml vs. （0.612±0.071） ng/ml vs. （0.428±0.074） ng/ml, P 〈0.0001 respectively） in the NRB group was lower than that in the R group and NR group. Conclusions The blood perfusion in the nonculprit artery may be impaired in patients with STEMI. Although nonculprit artery perfusion may be improved after successful primary PCI, it is still lower than that in the control group, and may be involved in inflammation and spasms.

Comparison of tirofiban combined with dalteparin or unfractionated heparin in primary percutaneous coronary intervention of acute ST-segment elevation myocardial infarction patients

Background Primary percutaneous coronary intervention （PCI） is the best treatment of choice for acute ST segment elevation myocardial infarction （STEMI）. This study aimed to determine the clinical outcomes of tirofiban combined with the low molecular weight heparin （LMWH）, dalteparin, in primary PCI patients with acute STEMI. Methods From February 2006 to July 2006, a total of 120 patients with STEMI treated with primary PCI were randomised to 2 groups： unfractionated heparin （UFH） with tirofiban （group I： 60 patients, （61.2±9.5） years）, and dalteparin with tirofiban （group il： 60 patients, （60.5±10.1） years）. Major adverse cardiac events （MACE） during hospitalization and at 4 years after PCI were examined. Bleeding complications during hospitalization were also examined. Results There were no significant differences in sex, mean age, risk factors, past history, inflammatory marker, or echocardiography between the 2 groups. In terms of the target vessel and vascular complexity, there were no significant differences between the 2 groups. During the first 7 days, emergent revascularization occurred only in 1 patient （1.7%） in group I. Acute myocardial infarction （AMI） occurred in 1 （1.7%） patient in group I and in 1 （1.7%） in group II. Three （5.0%） patients in group I and 1 （1.7%） in group II died. Total in-hospital MACE during the first 7 days was 4 （6.7%） in group I and 2 （3.3%） in group Ⅱ. Bleeding complications were observed in 10 patients （16.7%） in group I and in 4 patients （6.7%） in group II, however, the difference was not statistically significant. No significant intracranial bleeding was observed in either group. Four years after PCI, death occurred in 5 （8.3%） patients in group I and in 4 （6.7%） in group Ⅱ. MACE occurred in 12 （20.0%） patients in group I and in 10 （16,7%） patients in group Ⅱ. Conclusions Dalteparin was effective and safe in primary PCI of STEMI patients and combined dalteparin with tirofiban was effective and safe without significant bleeding complications compared with UFH. Although there was no statistically significant difference, LMWH decreased the bleeding complications compared with UFH.

Effect of reperfusion strategy on QT dispersion in patients with acute myocardial infarction:Impact on in-hospital arrhythmia

BACKGROUND Myocardial ischemia and ST-elevation myocardial infarction(STEMI)increase QT dispersion(QTD)and corrected QT dispersion(QTcD),and are also associated with ventricular arrhythmia.AIM To evaluate the effects of reperfusion strategy[primary percutaneous coronary intervention(PPCI)or fibrinolytic therapy]on QTD and QTcD in STEMI patients and assess the impact of the chosen strategy on the occurrence of in-hospital arrhythmia.METHODS This prospective,observational,multicenter study included 240 patients admitted with STEMI who were treated with either PPCI(group I)or fibrinolytic therapy(group II).QTD and QTcD were measured on admission and 24 hr after reperfusion,and patients were observed to detect in-hospital arrhythmia.RESULTS There were significant reductions in QTD and QTcD from admission to 24 hr in both group I and group II patients.QTD and QTcD were found to be shorter in group I patients at 24 hr than those in group II(53±19 msec vs 60±18 msec,P=0.005 and 60±21 msec vs 69+22 msec,P=0.003,respectively).The occurrence of in-hospital arrhythmia was significantly more frequent in group II than in group I(25 patients,20.8%vs 8 patients,6.7%,P=0.001).Furthermore,QTD and QTcD were higher in patients with in-hospital arrhythmia than those without(P=0.001 and P=0.02,respectively).CONCLUSION In STEMI patients,PPCI and fibrinolytic therapy effectively reduced QTD and QTcD,with a higher observed reduction using PPCI.PPCI was associated with a lower incidence of in-hospital arrhythmia than fibrinolytic therapy.In addition,QTD and QTcD were shorter in patients not experiencing in-hospital arrhythmia than those with arrhythmia.

Immediate in-hospital outcomes after percutaneous revascularization of acute myocardial infarction complicated by cardiogenic shock

BACKGROUND Cardiogenic shock(CS)is a life-threatening complication of acute myocardial infarction with high morbidity and mortality rates.Primary percutaneous coro-nary intervention(PCI)has been shown to improve outcomes in patients with CS.AIM To investigate the immediate mortality rates in patients with CS undergoing primary PCI and identify mortality predictors.METHODS We conducted a retrospective analysis of 305 patients with CS who underwent primary PCI at the National Institute of Cardiovascular Diseases,Karachi,Pak-istan,between January 2018 and December 2022.The primary outcome was immediate mortality,defined as mortality within index hospitalization.Uni-variate and multivariate logistic regression analyses were performed to identify predictors of immediate mortality.RESULTS In a sample of 305 patients with 72.8%male patients and a mean age of 58.1±11.8 years,the immediate mortality rate was found to be 54.8%(167).Multivariable analysis identified Killip class IV at presentation[odds ratio(OR):2.0;95%co-nfidence interval(CI):1.2-3.4;P=0.008],Multivessel disease(OR:3.5;95%CI:1.8-6.9;P<0.001),and high thrombus burden(OR:2.6;95%CI:1.4-4.9;P=0.003)as independent predictors of immediate mortality.CONCLUSION Immediate mortality rate in patients with CS undergoing primary PCI remains high despite advances in treatment strategies.Killip class IV at presentation,multivessel disease,and high thrombus burden(grade≥4)were identified as independent predictors of immediate mortality.These findings underscore the need for aggressive management and close monitoring of patients with CS undergoing primary PCI,particularly in those with these high-risk characteristics.