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.

Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions

Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries(MINOCA).This acute coronary syndrome differs from type 1 myocardial infarction(MI)regarding patient characteristics,presentation,physiopathology,management,treatment,and prognosis.Two-thirds of MINOCA subjects present ST-segment elevation;MINOCA patients are younger,are more often female and tend to have fewer cardiovascular risk factors.Moreover,MINOCA is a working diagnosis,and defining the aetiologic mechanism is relevant because it affects patient care and prognosis.In the absence of relevant coronary artery disease,myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries,coronary microcirculation,or both.Epicardial causes of MINOCA include coronary plaque disruption,coronary dissection,and coronary spasm.Microvascular MINOCA mechanisms involve microvascular coronary spasm,takotsubo syndrome(TTS),myocarditis,and coronary thromboembolism.Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients.The diagnostic arsenal includes invasive and non-invasive techniques.Medical history and echocardiography can help indicate vasospasm or thrombosis,if one finite coronary territory is affected,or specify TTS if apical ballooning is present.Intravascular ultrasound,optical coherence tomography,and provocative testing are encouraged.Cardiac magnetic resonance is a cornerstone in myocarditis diagnosis.MINOCA is not a benign diagnosis,and its polymorphic forms differ in prognosis.MINOCA care varies across centres,and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.

Risk of ventricular arrhythmia in patients with myocardial infarction and non-obstructive coronary arteries and normal ejection fraction

AIM To assess the arrhythmic determinants and prognosis of patients presenting with myocardial infarction and nonobstructive coronary arteries(MINOCA)with normal ejection fraction(EF).METHODS This is an observational analysis of 131 MINOCA patients with normal EF.Three cardiac magnetic resonance(CMR)diagnosis classes were recognized according to the late gadolinium enhancement(LGE)pattern:Myocardial infarction(MI)(n=34),myocarditis(n=47),and"no LGE"(n=50).Ventricular events occurring during hospitalization were recorded and the entire population was followed-up at 1 year.RESULTS Ventricular arrhythmia was observed in 18(13.8%)patients during hospitalization.The"no LGE"patients experienced fewer ventricular events than the MI and myocarditis patients[4.0%vs 26.5%and 14.9%,respectively(P=0.013)].There was no significant difference between the MI and myocarditis groups.On multivariate analysis,LGE transmural extent[OR=1.52(1.08-2.15),P=0.017]and ST-segment elevation[OR=4.65(1.61-13.40),P=0.004]were independent predictors of ventricular arrhythmic events,irrespective of the diagnosis class.Finally,no patient experienced sudden cardiac death or ventricular arrhythmia recurrence at 1-year.CONCLUSION MINOCA patients with normal EF presented no 1-year cardiovascular events,irrespective of the CMR diagnosis class.LGE transmural extent and ST segment elevation at admission are risk markers of ventricular arrhythmia during hospitalization.

Presentation and outcome of myocardial infarction with nonobstructive coronary arteries in coronavirus disease 2019

Among the cardiac complications of coronavirus disease 2019(COVID-19),one increasingly reported in the literature is myocardial infarction with nonobstructive coronaries(MINOCA).We reviewed all reported cases of MINOCA in COVID-19 patients to summarize its clinical features,evaluation,and treatment.We performed a literature search in Pubmed using the search terms‘COVID-19’and‘MINOCA’or‘non-obstructive coronaries’.Among the reported cases,the mean age was 61.5 years(SD±13.4),and 50%were men.Chest pain was the presenting symptom in five patients(62.5%),and hypertension was the most common comorbidity(62.5%).ST-elevation was seen in most patients(87.5%),and the overall mortality rate was 37.5%.MINOCA in COVID-19 is an entity with a broad differential diagnosis.Therefore,a uniform algorithm is needed in its evaluation to ensure timely diagnosis and management.

Acute myocardial infarction triggering Takotsubo syndrome, and the need to search for its prevalence

To the Editor The interesting report by Redfors, et aL[1] in the June issue of the Journal of Geriatric Cardiology, about an 88-year-old woman who presented with chest pain, found on echocardiography （ECHO） to have transient left ventricular apical akinesis with a hypercontractile base, and an occluded first diagonal coronary branch with suspected acute plaque rupture, on coronary angiography, treated with a percutaneous coronary intervention, for which the authors concluded that the observed extent of akinesis was disproportionally large for the occluded coronary lesion, letting them to deduce that the acute myocardial infarction （AMI） caused the episode of Takotsubo syndrome （TTS）, reminds me of a similar case of an AMI due to stent thrombosis and a resultant associated TTS.

Clinical Survey of 6 371 In-Paitent Cases of Acute Myocardial Infarction from 1984 to 1992 in Guangdong Province

6 371 cases of acute myocardialinfarction from 1984 to 1992 in Guangdong Province are reported in this article. The results show that the prevalence rate of acute myocardial infarction (AMI) has been increasing. The anterior walls are involved more often than the inferior ones are. The first symptom in 87. 4% of cases is pectoral pain. The most common complications are arrhythmia, heart failure and cardiac shock successively occurring in order. The mortality rate is 19.9%. The predominant causes of death is pump failure.

Early and Late Coronary Angiographic Changes After Thrombolysis in Acute Myocardial Infarciton

Objective The coronaryanatomic feature and development after thrombolysis in acute myocardial infarction (AMI) were studied. Mehtods 100 patients with AMI received urokinase and strepokinase. Coronary angiography (CAG) was performed at 90 minuts and again at 3 to 4 weeks. Results Successful thrombolysis occurred in 60 cases, but failed in 40. The ratio of reperfusion was 60%. CAG showed there were residual thrombi in 84 patients (84% ) and complete coronary occlusion in 40(40% ). Angiography at 3 to 4 weeks after thrombolysis showed the stenosis worsened in 8 patients and improved in 10. Conclusion AMI is caused by sudden coronary thrombotic occlusion and can be reperfused by using thrombolytic agent or mechanical methods. Throm-bolytic agents usually can not resolve thrombi completely. So percutaneous transluminal coronary angiography (PTCA) is recommended as an important method to improve serious residual stenosis.

Beneficial Effects of Delayed Opening the Infarct - related Artery on Late Phase Left Ventricular Function in Acute Anterior Myocardial Infarction

Objectives To assess the effect of delayed opening the infarct - related artery (IRA) by percutanous coronary intervention (PCI) on the late phase left ventricular function after acute ante- rior myocardial infarction. Methods 64 patients with initial Q - wave anterior myocardial infarction and the infarct - related arteries were total occluded conformed by angiogram at 2 to 14 days after onset were divided into successful PCI group and control group ( not re- ceiving PCI or the IRA not re - opened). 2 - DE was performed at early phase ( about 3 weeks) , 2 and 6 months after onset of AMI respectively to detect the left ventricular function and left ventricular wall motion ab- normality (VWMA). The total congestive heart failure events were recorded during 6 months follow-up. Re- sults VWMA scores, left ventricular ejection frac- tion (LVEF) , left ventricular end - diastolic and end - systolic volume indices ( LVEDVI and LVDSVI) were similar in 2 groups at early phase and 2 months. There were no differences between early phase and 2 months in each group too. VWMA scores and LVEF did not changed at 6 months in each group compared with the early phase and 2 months ( P > 0. 05 ). But LVEDVI and LVESVI were significantly smaller in the successful PCI group than in the control group (P < 0.01, P < 0. 05). The congestive heart failure events were taken place in 19% of patients in control group com- pared with 2% in successful PCI group ( P > 0. 05 ). Conclusions Although the infarct size does not changed, delayed opening the IRA has beneficial effect to the late phase left ventricular dilatation after acuteanterior myocardial infarction.

HDL signaling and protection against coronary artery atherosclerosis in mice

Atherosclerosis is a leading underlying factor in cardiovascular disease and stroke,important causes of morbidity and mortality across the globe.Abundant epidemiological studies demonstrate that high levels of high density lipoprotein（HDL） are associated with reduced risk of atherosclerosis and preclinical,animal model studies demonstrate that this association is causative.Understanding the molecular mechanisms underlying the protective effects of HDL will allow more strategic approaches to development of HDL based therapeutics.Recent evidence suggests that an important aspect of the ability of HDL to protect against atherosclerosis is its ability to trigger signaling responses in a variety of target cells including endothelial cells and macrophages in the vessel wall.These signaling responses require the HDL receptor,scavenger receptor class B type 1（SR-B1）,an adaptor protein（PDZK1） that binds to the cytosolic C terminus of SR-B1,Akt1 activation and（at least in endothelial cells） activation of endothelial NO synthase（eNOS）.Mouse models of atherosclerosis,exemplified by apolipoprotein E or low density lipoprotein receptor gene inactivated mice（apoE or LDLR KO） develop atherosclerosis in their aortas but appear generally resistant to coronary artery atherosclerosis.On the other hand,inactivation of each of the components of HDL signaling（above）in either apoE or LDLR KO mice renders them susceptible to extensive coronary artery atherosclerosis suggesting that HDL signaling may play an important role in protection against coronary artery disease.

ASSOCIATION OF INSULIN RESISTANCE AND C-REACTIVE PROTEIN WITH CORONARY ARTERY DISEASE IN PATIENTS WITH NORMAL GLUCOSE TOLERANCE

Objective To examine insulin resistance and high sensitivity C-reactive protein （hsCRP） association with clinical and angiographic severity of coronary artery disease （CAD） in patients with normal glucose tolerance. Methods In 638 consecutive patients with normal glucose tolerance, 221 had atypical chest pain and normal coronary artery （control group）, 279 had stable angina and CAD （SAP group ）, and 138 suffered acute myocardial infarction （ MI group）. The degree of CAD was further divided into borderline lesion （ lumen diameter narrowing 50% - 69% ）, significant 1-, 2- or 3-vessel disease （ luminal diameter narrowing 〉I 70% ）. Fasting serum glucose, insulin and hsCRP levels and lipid profiles were measured, and homeostasis model assessment for insulin resistance （ HOMA-IR ） was calculated. Multivariate analysis was performed to assess risk factors for 3-vessel disease or acute MI. Results Serum hsCRP, lipoprotein （a） levels, and insulin resistance index （IRI） were higher in AMI group than those in SAP and control groups. Serum hsCRP level and IRI were also higher in 3-vessel disease than those in other groups. Multivariate regression analysis revealed that insulin resistance, cigarette smoking, serum hsCRP, and lipoprotein （a） levels were independent risk factors for acute MI. Lipoprotein （ a ） elevation was an independent risk factor for 3-vessel disease. Conclusion Insulin resistance and high serum hsCRP level were associated with occurrence of acute MI and angiographic severity of coronary disease in patients with normal glucose tolerance.

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.

Polymorphisms in the coagulation factor Ⅶ gene and the risk of myocardial infarction in patients undergoing coronary angiography

Objective To investigate whether coagulation factor Ⅶ (FⅦ) polymorphisms play a role in the pathogenesis of coronary artery disease (CAD) and/or myocardial infarction (MI) in a series of Hans.Methods The Arg 353 Gln and HVR4 polymorphisms of FⅦ gene were determined in 374 patients undergoing selective coronary angiography by PCR and restriction fragment length polymorphism assay.Results The FⅦ genotype distribution was in accordance with Hardy-Weinberg equilibrium. The frequencies of FⅦ genotypes or alleles did not show significant differences between the CAD group and the controls or between the males and the females. The frequencies of carriers of the Gln 353 allele and (Arg/Gln+Gln/Gln) genotypes were significantly higher in the CAD patients without MI than in those with MI ( P =0.031,odds ratio 0.37,95% CI: 0.15-0.94). However,HVR4 polymorphisms were not significantly different between the two groups ( P >0.05).Conclusion Carrying the F Ⅶ Gln 353 gene may be a protective factor against MI in the Chinese Hans.

The impact of different doses of atorvastatin on plasma endothelin and platelet function in acute ST-segment elevation myocardial infarction after emergency percutaneous coronary intervention

Objective To investigate the effects of different doses of atorvastatin on plasma endothelin and platelet function in acute ST-segment elevation myocardial infarction(STEMI)patients after emergency percutaneous coronary intervention(PCI).Methods A total of 120 patients with acute STEMI treated with emergency PCI were enrolled and randomly divided into 20 mg of atorvastatin treatment group(standard group,n=60),and 40 mg of atorvastatin treatment group(intensive group,n=60).

Coronary artery dissection and acute myocardial infarction after blunt chest trauma

Coronary artery dissection and acute myocar-dial infarction（AMI） after blunt chest trauma （BCT） has rarely been reported1＇2. This report describes two cases of the left anterior de-scending（LAD） artery dissection and AMI after BCT, successfully treated with percutaneous coronary intervention （PCI） and they dis-charged without complications.

Acute myocardial infarction associated with coronary spasm in a young man

CASE REPORT Acute myocardial infarction （AMI） is usually caused by atherosclerotic plaque disruption and thrombus formation. However, AMI is occasionally caused by coronary spasm too. We are reporting a case with AMI due to coronary spasm whose serial electrocardiogram （ECG） showed dynamic changes of T waves in precordial leads.

Recurrent myocardial infarctions with normal coronary arteries in a patient with atrial flutter: A case report

Coronary embolism secondary to atrial fibrillation can lead to myocardial infarction independently of atherosclerotic coronary arteries. We encountered a patient repeatedly tortured by atrial fibrillation who presented with recurrent myocardial infarctions with normal coronary anatomy and ischemic stroke. We were frustrated by repeated failures because of some probably inappropriate decisions.

Acute myocardial infarction due to myocardial bridge

Myocardial bridge （MB） is regarded as a common .anatomic variant rather than a congenital conditionanomaly, defined as the intrainyocardial course of a portion of the coronary artery. It was first mentioned by Rayman in 1737 and first described by Grainicianu in the early 1920s. The current gold standard tor diagnosing MB is coronary angiography with the typical systolic compression of the epicardial coronary vessel （milking effect）.

Acute myocardial infarction after capecitabine treatment： not always vasospasm is responsible

Capecitabine is an orally available chemotherapeutic agent that is converted to 5-fluorouracil （5-FU） after absorbtion. Capecitabine and its active metabolite, 5-FU, have cardiotoxic effects with reported instances of acute coronary syndromes caused due to coronary vasospasm. However, these agents exert toxic effects on cardiovascular system and beyond vasospasm provacation. We report a 46-year-old patient diagnosed as acute inferior infarction who is treated with capecitabine for 3 months due to metastatic breast carcinoma, in whom thrombotic coronary occlusion was observed in angiography. This case demonstrates that apart from vasospasm, coronary thrombosis could be observed after capecitabine treatment, with a possible direct effect of this drug.

In-Hospital Cardiac Arrest after Emotional Stress in a Patient Hospitalized with Gastrointestinal Symptoms and Chronic Anxiety Disorder

Background:We report an acute emotional stress-induced in-hospital cardiac arrest in a patient admitted with gas-trointestinal symptoms after experiencing chronic anxiety disorder.Case Presentation:The patient was admitted to the Second Xiangya Hospital,Central South University,with gastrointestinal symptoms and chronic anxiety disorder,and experienced cardiac arrest during hospitalization after acute emotional stress.Malignant ventricular tachycardia and cardiogenic shock were evidenced in this patient after the acute emotional stress.Severe and extensive coronary spasm was confi rmed by emergency coronary angiography,and coronary spasm was relieved by intracoronary injection of nitroglycerin.The patient recovered from myocardial infarction with nonobstructive coronary arteries.However,the patient developed acute kidney dysfunction and severe pulmonary infection and eventually died of respiratory circulatory failure on the ninth day after the successful rescue.Conclusions:Acute emotional stress on top of chronic anxiety disorder in patients hospitalized for noncardiovascu-lar reasons might lead to the development of life-threatening cardiovascular diseases,including coronary artery spasm and myocardial infarction with nonobstructive coronary arteries.Psychological management is of importance to im-prove the outcome of these patients.