Challenges in managing ST elevation myocardial infarction during the COVID-19 pandemic

BACKGROUND Coronavirus disease 2019(COVID-19)may contribute to delayed presentations of acute myocardial infarction.Delayed presentation with late reperfusion is often associated with an increased risk of mechanical complications and adverse outcomes.Inherent delays are possible as every patient who is acutely sick is being considered a potential case or a career of COVID-19.Also,standardized personal protective equipment precautions are established for all members of the team,regardless of pending COVID-19 testing which might further add to delays.AIM To compare performance measures and clinical outcomes of all patients who presented to our facility with ST elevation myocardial infarction(STEMI)during the COVID-19 pandemic to same time cohort from 2019.METHODS All patients who presented to our facility with STEMI during the pandemic were compared to a matched cohort during the same time period in 2019.STEMI with unknown time of symptom onset and inpatient STEMI patients were excluded.Primary outcome was major adverse cardiac events(MACE)in-hospital and up to 14 d after STEMI,including death,myocardial infarction,cardiac arrest,or stroke.Significant differences among groups for continuous variables were tested through ANOVA,using SYSTAT,version 13.Chi-square tests of association were used to compare patient characteristics among groups using SYSTAT.Relative risk scores and associated tests for significance were calculated for discrete variables using MedCalc(MedCalc Software,Ostend,Belgium).RESULTS There was a significantly longer time interval from symptom onset to first medical contact(FMC)in the COVID-19 group(P<0.02).Time to first electrocardiogram,door-to-balloon time,and FMC to balloon time were not significantly affected.The right coronary artery was the most common culprit for STEMI in both the cohorts.Over 60%of patients had one or more obstructive(>50%)lesion(s)remote from the culprit site.In-hospital and 14 d MACE were more prevalent in the COVID-19 group(P<0.01 and P<0.001).CONCLUSION This single academic center study in the United States suggests that there is a delay in patients with STEMI seeking medical attention during the COVID-19 pandemic which could be translating into worse clinical outcomes.

Study of Adverse Events of Streptokinase Therapy in Patients with Acute ST Elevation Myocardial Infarction

Background: Despite of different adverse events, streptokinase (SK) is widely used to treat patients presented with acute ST segment elevation myocardial infarction. Objective: The purpose of the present study was to observe different adverse events in patients of acute ST segment elevation myocardial infarction receiving SK infusion. Methodology: This cross-sectional type of analytic observational study was carried out in the inpatient department of Cardiology at National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from December 23rd 2019 to February 22nd 2020 for a period of two (2) months. All patients diagnosed as acute ST segment elevation myocardial infarction receiving SK were included in the present study. Adverse events were documented through completing a questionnaire by reviewing the records in the medical file as well as interviewing with the patients. Result: In this study, 43 (26.2%) patients developed different types of adverse events and 121 (73.8%) had no complications following SK infusion. The most common adverse event was hypotension i.e. 26 (60.4%) and other adverse events were bleeding 8 (4.8%) and allergic reaction 7 (4.2%). Statistically significant higher rate of adverse events occurred in diabetic, hypertensive and dyslipidemia group which was 26 (56.5%) Vs. 17 (14.4%), p = 0.000, 37 (36.6%) Vs. 06 (09.5%), p = 0.000 and 18 (54.5%) Vs. 25 (19.1%), p = 0.000 respectively. The independent factors for the development of adverse events were smoking {OR: 5.1 with 95% CI (1.7 to 15.1), p = 0.003}, diabetes {OR: 14.9 with 95% CI (5.0 to 44.8), p = 0.000}, hypertension {OR: 5.1with 95% CI (1.7 to 15.1), p = 0.003} and dyslipidemia {OR: 4.6 with 95% CI (1.5 to 13.7), p = 0.007}. Conclusion: Streptokinase infusion was associated with different adverse events. Among them the commonest one was hypotension and other less common events were minor bleeding and minor allergic reaction. The adverse events were more frequently documented in patients who were smoker, diabetic, hypertensive and dyslipidemic.

Plaque herniation after stenting the culprit lesion with myocardial bridging in ST elevation myocardial infarction: A case report

BACKGROUND Myocardial bridging(MB)is increasingly recognized to stimulate atherogenesis,which may contribute to an acute coronary syndrome.Stenting the coronary segment with MB has been recognized to have an increased risk of in-stent restenosis,stent fracture and coronary perforation.The safety and efficacy of stenting the culprit lesion with overlaying MB in ST elevation myocardial infarction(STEMI)as primary reperfusion therapy has not been established.CASE SUMMARY We reported a patient who presented with inferior STEMI with a culprit lesion of an acute thrombotic occlusion in the right coronary artery and thrombolysis and thrombin inhibition in myocardial infarction 0 flow.After the stent placement during primary percutaneous coronary intervention,intravascular ultrasound revealed MB overlying the stented segment where heavy atherosclerotic plaque were present.Likely due to the combination of plaque herniation or prolapse caused by MB,as well as local increased inflammation and thrombogenicity,acute stent thrombosis occurred at this region,which led to acute stent failure.The patient required an emergent repeated cardiac catheterization and placing a second layer of stent to enhance the radial strength and reduce the inter-strut space.CONCLUSION Plaque herniation or prolapse after stenting a MB segment in STEMI is a potential etiology for acute stent failure.

Changes in process and outcome for ST elevation myocardial infarction in central China from 2011 to 2018

Background:Limited data are available on the changes in the quality of care for ST elevation myocardial infarction(STEMI)during China’s health system reform from 2009 to 2020.This study aimed to assess the changes in care processes and outcome for STEMI patients in Henan province of central China between 2011 and 2018.Methods:We compared the data from the Henan STEMI survey conducted in 2011-2012(n=1548,a cross-sectional study)and the Henan STEMI registry in 2016-2018(n=4748,a multicenter,prospective observational study).Changes in care processes and in-hospital mortality were determined.Process of care measures included reperfusion therapies,aspirin,P2Y12 antagonists,β-blockers,angiotensin-converting enzyme inhibitors or angiotensin receptor blockers,and statins.Therapy use was analyzed among patients who were considered ideal candidates for treatment.Results:STEMI patients in 2016-2018 were younger(median age:63.1 vs.63.8 years)with a lower proportion of women(24.4%[1156/4748]vs.28.2%[437/1548])than in 2011-2012.The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018(60.9%[5424/8901]vs.82.7%[22,439/27,129],P<0.001).The proportion of patients treated by reperfusion within 12 h increased from 44.1%(546/1237)to 78.4%(2698/3440)(P<0.001)with a prolonged median onset-to-first medical contact time(from 144 min to 210 min,P<0.001).The use of antiplatelet agents,statins,andβ-blockers increased significantly.The risk of in-hospital mortality significantly decreased over time(6.1%[95/1548]vs.4.2%[198/4748],odds ratio[OR]:0.67,95%confidence interval[CI]:0.50-0.88,P=0.005)after adjustment.Conclusions:Gradual implementation of the guideline-recommended treatments in STEMI patients from 2011 to 2018 has been associated with decreased in-hospital mortality.However,gaps persist between clinical practice and guideline recommendation.Public awareness,reperfusion strategies,and construction of chest pain centers need to be further underscored in central China.

Effect of Intravenous Administration of Liposomal Prostaglandin E1 on Microcirculation in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Intervention

Background：Several studies have demonstrated that primary percutaneous coronary intervention （PCI） can result in reperfusion injury.This study aims to investigate the effectiveness of liposomal prostaglandin E l （Lipo-PGE1,Alprostadil,Beijing Tide Pharmaceutical Co.,Ltd.） for enhancing microcirculation in reperfusion injury.In addition,this study determined the optimal administration method for acute ST elevation myocardial infarction （STEMI） patients undergoing primary PCI.Methods：Totally,68 patients with STEMI were randomly assigned to two groups：intravenous administration ofLipo-PGE 1 （Group A）,and no Lipo-PGE1 administration （Group B）.The corrected thrombolysis in myocardial infarction （TIMI） frame count （cTFC） and myocardial blush grade （MBG） were calculated.Patients were followed up for 6 months.Major adverse cardiac events （MACE） were also measured.Results：There was no significant difference in the baseline characteristics between the two groups.The cTFC parameter in Group A was significantly lower than Group B （18.06 ± 2.06 vs.25.31 ± 2.59,P ＜ 0.01）.The ratio of final MBG grade-3 was significantly higher （P ＜ 0.05） in Group A （87.9％） relative to Group B （65.7％）.There was no significant difference between the two groups in final TIMI-3 flow and no-reflow.Patients were followed up for 6 months,and the occurrence of MACE in Group A was significantly lower than that in Group B （6.1％ vs.25.9％ respectively,P ＜ 0.05）.Conclusions：Myocardial microcirculation of reperfusion injury in patients with STEMI,after primary PCI,can be improved by administering Lipo-PGE1.

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.

State of the art contemporary treatment of patients with ST elevationmyocardial infarction： pre- and in-hospital organization, devices anddrugs

Objective To review the presentation,diagnosis and recent developments in the pharmacological and invasive treatment of ST elevation myocardial infarction (STEMI) with a special focus on health-care organization in order to increase accessibility of primary pemutaneous coronary intervention (PCI).Data sources Data were obtained from English publications on STEMI treatment.No formal systematic review was conducted,but an effort was made to be comprehensive.Study selection Studies were selected if they contained data relevant to the topic.Preferably,data from clinical randomized trials,meta-analyses,guidelines and a few recent reviews are referenced.Results The described clinical approach to acute myocardial infarction (AMI) has been a continuum of scientific results and translation into clinical practice over the last four decades since the advent of thrombolytic reperfusion.This has resulted in a dramatic in-hospital mortality decrease from 30% in the 1960s to the present 5%.The biggest survival benefits have undoubtedly been achieved after the advent of reperfusion strategies.In contemporary treatment of STEMI,additional treatment effects on survival have to be sought in the very early admission phase,as the current mortality hazard drops significantly after the first critical days to continuously very low levels after discharge.Conclusions Optimal treatment of STEMI patients is best performed with a widely accessible reperfusion strategy,preferably primary PCI,with contemporary peri-procedural anti-thrombotic treatment and device implantation.Accessibility of reperfusion strategies is increased by efficient STEMI networks applying prehospital triage with digital tele-transmission of electrocardiograms (ECGs) and seamless patient transitions between health-care unities.Efficient treatments of complicated STEMI with out-of hospital cardiac arrest and/or cardiogenic shock underline the necessity of structured referral systems,preferably immediately after the initial STEMI diagnosis。

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.

ST-segment elevation myocardial infarction in Kawasaki disease:A case report and review of literature

BACKGROUND Kawasaki disease(KD)is an acute self-limiting febrile vasculitis that occurs during childhood and can cause coronary artery aneurysm(CAA).CAAs are associated with a high rate of adverse cardiovascular events.CASE SUMMARY A Korean 35-year-old man with a 30-year history of KD presented to the emergency room with chest pain.Emergent coronary angiography was performed as ST-segment elevation in the inferior leads was observed on the electrocardiogram.An aneurysm of the left circumflex(LCX)coronary artery was found with massive thrombi within.A drug-eluting 4.5 mm 23 mm-sized stent was inserted into the occluded area without complications.The maximal diameter of the LCX was 6.0 mm with a Z score of 4.7,suggestive of a small aneurysm considering his age,sex,and body surface area.We further present a case series of 19 patients with KD,including the current patient,presenting with acute coronary syndrome(ACS).Notably,none of the cases showed Z scores;only five patients(26%)had been regularly followed up by a physician,and only one patient(5.3%)was being treated with antithrombotic therapy before ACS occurred.CONCLUSION For KD presenting with ACS,regular follow up and medical therapy may be crucial for improved outcomes.

Relationship between serum CRP level and left ventricular function in patients with acute ST-elevation myocardial infarction: A cross-sectional study

Objective: To investigate the relationship between serum C-reactive protein (CRP) level and left ventricular function in patients with acute ST-elevation myocardial infarction. Methods: This study is a descriptive-analytic study and was conducted on patients with ST-elevation myocardial infarction, who were admitted to the Urmia Hospital in Seyed Alshohada Hospital, and underwent primary percutaneous coronary intervention from October to March 2018. Demographic, angiographic, echocardiographic data were evaluated based on the patients' records. All patients were evaluated for 90 min and CRP levels were measured during the first 6 h after the primary percutaneous coronary intervention. Results: A total of 114 patients were studied, among whom 71.9%(82 patients) were male, and their mean age was (57.86±9.57) years old. The mean BMI was (26.1±3.8) kg/m2. Altogether 38.6%(44 patients) had a history of smoking, 17.5% (20 patients) of diabetes, 38.6% (44 patients) of hypertension, 5.3% (6 patients) of hyperlipidemia and 7.0% (8 patient) of coronary artery disease. The results showed a significantly negative correlation between ejection fraction and CRP, left atrial volume and CRP (P<0.05), and a significantly positive correlation between the global longitudinal strain level and CRP. The CRP level was significantly different at various diastolic grades (P=0.001). The level of CRP in patients with grade 2 diastolic dysfunction was higher than grade 1 diastolic dysfunction, while the level of CRP in diastolic grade 1 diastolic dysfunction was higher than the normal function. Conclusions: High CRP levels are associated with ejection fraction, global longitudinal strain loss and left atrial volume.

Effect of late reperfusion therapy on cardiac function and prognosis in patients with acute ST elevation myocardial infarction

Background The suitable time for treating patients with acute ST elevation myocardial infarction （STEMI） is unclear. This study was to investigate the effects of reperfusion therapy at different late times on patients with acute STEMI, in order to decide the best time for late reperfusion therapy by providing evidence-based treatment in clinical practice. Methods We enrolled 1372 patients with STEMI and receiving selective percutaneous coro- nary intervention therapy between January 1st, 2010 to December 30th, 2014. According to the time receiving PCI, these patients were divided into 3 groups： 〈3 d（n=66） ,3-6 d（n=388） and/〉7 d （n=918）. The demograph- ic, clinical and coronary angiography data, and in-hospital major adverse clinical events （MACEs） were com- pared. Results The mortality rates among 3 groups were not statistically different （0 vs. 2.6% vs. 2.0%, P= 0.375）. The incidence rate of in-hospital MACEs in 3-6 d group was lower than the other two groups, but not sta- tistic difference （25.8% vs. 16.8% vs. 21.6%, P=0.077）. By comparing the cost of hospitalization, we found that the 3-6 d group was slight lower. For patients with non-occlusive culprit vessels, although the mortality rate still had no statistic difference, the incidence rates of in-hospital MACEs were different （33.3% vs. 11.7% vs. 15.9%, P=0.003）. However, the same conclusion was not driven in patients with occlusive target vessels. Conclusions For patients with STEMI receiving late reperfusion therapy, intervention during 3-6 d might have a trend to improve prognosis.

Comparison of different risk scores in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background The early detection of high-risk patients with primary percutaneous coronary intervention（PPCI） is important in reducing the risk of death in patients with acute ST elevation myocardial infarction（STEMI）. We aimed to compare the prognostic value of validated risk scores for in-hospital and one-year death. Methods This study enrolled a series of patients with acute STEMI who underwent PPCI. Thrombolysis in Myocardial Infarction（TIMI） risk score, Korea Acute Myocardial Infarction Registry（KAMIR） score, Canada Acute Coronary Syndrome（C-ACS） and Age, Glomerular filtration rate, and Ejection Fraction（AGEF） were calculated. The prognostic accuracy of the 4 scores for in-hospital and one-year death was assessed. Results A total of 489 patients with acute STEMI were retrospectively included in the present study. There were 16（3.3%） patients died while in hospital. AGEF had higher predictive power for in-hospital death than KAMIR score（0.894 vs. 0.816,P = 0.048） and C-ACS（0.894 vs. 0.728, P = 0.038）. No statistical significance was found when comparing with TIMI risk score（0.894 vs. 0.795, P = 0.124）. There were 33 patients died in 459（93.9%） included patients completed one-year follow up. The AUC of TIMI risk score, KAMIR score, C-ACS and AGEF in predicting one-year death was 0.728, 0.718, 0.681 and 0.772, respectively. They had similarly prognostic value for one-year mortality（P 〉 0.05）. Conclusion The AGEF risk scores appear to have slightly better prognostic value for the in-hospital and one-year mortality in patients with acute STEMI receiving PPCI.

ST-Segment Elevation Mimicking STEMI Due to Hypercalcemia: A Case Report

ST-segment elevation myocardial infarction (STEMI) is an important, life-threatening diagnosis that requires quick diagnosis and treatment, characteristic ECG of which shows ST-segment elevation. Unfortunately, ST-segment elevation is nonspecific, which can be misleading if not careful to be interpreted, as in this case of hypercalcemia seen by us. A 48-year-old male was admitted to our emergency department with recurrent chest pain, nausea and vomiting. Medical history includes hypertension and diabetes. ST-segment elevation in V1 - V4 mimicking STEMI was present on admission. However, immediate coronary angiography revealed nearly normal coronary arteries, his troponin was negative in 6 hours and calcium was 2.95 mmol/L. It was thought that the ECG changes were not indicative of cardiac ischemia but hypercalcemia. He was managed with calcium reduction treatment such as intravenous normal saline and furosemide, with subsequent resolution of ST-segment changes.

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.

Tenecteplase versus alteplase in treatment of acute ST-segment elevation myocardial infarction:A randomized non-inferiority trial

Background:A phase II trial on recombinant human tenecteplase tissue-type plasminogen activator(rhTNK-tPA)has previously shown its preliminary efficacy in ST elevation myocardial infarction(STEMI)patients.This study was designed as a pivotal postmarketing trial to compare its efficacy and safety with rrecombinant human tissue-type plasminogen activator alteplase(rt-PA)in Chinese patients with STEMI.Methods:In this multicenter,randomized,open-label,non-inferiority trial,patients with acute STEMI were randomly assigned(1:1)to receive an intravenous bolus of 16 mg rhTNK-tPA or an intravenous bolus of 8 mg rt-PA followed by an infusion of 42 mg in 90 min.The primary endpoint was recanalization defined by thrombolysis in myocardial infarction(TIMI)flow grade 2 or 3.The secondary endpoint was clinically justified recanalization.Other endpoints included 30-day major adverse cardiovascular and cerebrovascular events(MACCEs)and safety endpoints.Results:From July 2016 to September 2019,767 eligible patients were randomly assigned to receive rhTNK-tPA(n=384)or rt-PA(n=383).Among them,369 patients had coronary angiography data on TIMI flow,and 711 patients had data on clinically justified recanalization.Both used a–15%difference as the non-inferiority efficacy margin.In comparison to rt-PA,both the proportion of patients with TIMI grade 2 or 3 flow(78.3%[148/189]vs.81.7%[147/180];differences:–3.4%;95%confidence interval[CI]:–11.5%,4.8%)and clinically justified recanalization(85.4%[305/357]vs.85.9%[304/354];difference:–0.5%;95%CI:–5.6%,4.7%)in the rhTNK-tPA group were non-inferior.The occurrence of 30-day MACCEs(10.2%[39/384]vs.11.0%[42/383];hazard ratio:0.96;95%CI:0.61,1.50)did not differ significantly between groups.No safety outcomes significantly differed between groups.Conclusion:rhTNK-tPA was non-inferior to rt-PA in the effect of improving recanalization of the infarct-related artery,a validated surrogate of clinical outcomes,among Chinese patients with acute STEMI.Trial registration:www.ClinicalTrials.gov(No.NCT02835534).

Acute myocardial infarction after initially diagnosed with unprovoked venous thromboembolism: A case report

BACKGROUND Protein C deficiency is typically associated with venous thromboembolism;however,arterial thrombosis has been reported in several cases.We report the case of a patient with pulmonary thromboembolism and deep vein thrombosis following acute myocardial infarction with high thrombus burden.CASE SUMMARY A 40-year-old man was diagnosed with pulmonary thromboembolism and deep vein thrombosis without any provoking factors.The patient was treated with anticoagulants for six months,which were then discontinued.Three months after the discontinuation of anticoagulant therapy,the patient was hospitalized with chest pain and diagnosed with acute myocardial infarction with high thrombus burden.Additional tests revealed protein C deficiency associated with thrombophilia.The patient was treated with anticoagulants combined with dual antiplatelet agents for 1 year after percutaneous coronary intervention,and no recurrent events were reported during a follow-up period of 5 years.CONCLUSION Recurrent thromboembolic events including acute myocardial infarction with thrombus should be considered an alarming sign of thrombophilia.

1st degree acromioclavicular sprain, elevated 1st rib, or both? A case study of a rodeo cowboy

Objective: To present a case of a rodeo cowboy who suffered a seemingly routine 1st degree acromioclavicular (AC) sprain. The AC sprain was exacerbated by an elevated 1st rib. Background: Saddle bronc riding is one of three rough stock events in North American rodeo and the least common event for injury relative to bull riding and bareback riding. Shoulder injury in rodeo rough stock events make up 9.3% of all injuries. Approximately 28% of injuries in rodeo are considered minor sprains. The professional cowboy was thrown from his horse landing on the tip of his shoulder. The cowboy presented with a routine 1st degree AC sprain based on the Tossey and Rockwood definitions. Differential Diagnosis: Due to the mechanism of injury and forces produced with the cowboy being thrown to the ground, elimination of serious neck injury was critical. A scanning examination revealed some neck dysfunction. A cervical rotation, lateral flexion special test confirmed the additional elevated 1st rib in addition to the 1st degree AC sprain. Treatment: A chiropractic adjustment of the 1st rib reduced pain in the AC joint from a 6/10 to 1/10 immediately. Subsequently, the patient iced and was treated with one other 1st rib adjustment at a later date. Uniqueness: There were no cases of 1st degree AC sprains with an associated elevated first rib in the literature. It was very unique to relieve to the patient’s shoulder symptoms so dramatically in a short period of time with manual therapy to the first rib. Conclusions: It is important to follow a thorough history and physical examination of patients who suffer from a 1st degree AC sprain. The use of a scanning examination will help identify the primary source of pain (i.e. neck and/or shoulder). Manual therapy of the 1st rib may be useful in the treatment.

A randomized, prospective, two-center comparison of sirolimus-eluting stent and zotarolimus-eluting stent in acute ST-elevation myocardial infarction： The SEZE trial

Background The zotarolimus-eluting stent has shown larger in-stent late lumen loss compared to sirolimus-eluting stents in previous studies. However, this has not been thoroughly evaluated in ST elevation myocardial infarction. Methods This was a prospective, randomized, controlled trial evaluating angiographic outcomes in patients presenting with ST elevation myocardial infarction, treated with zotarolimus-eluting stents or sirolimus-eluting stents. From March 2007 to February 2009, 122 patients were randomized to zotarolimus-eluting stents or sirolimus-eluting stents in a 1：1 fashion. The primary endpoint was 9-month in-stent late lumen loss confirmed by coronary angiography, and secondary endpoints were percent diameter stenosis, binary restenosis rate, major adverse cardiac events （a composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization）, and late-acquired incomplete stent apposition. Results Angiographic in-stent late lumen loss was significantly higher in the zotarolimus-eluting stent group compared to the sirolimus-eluting stent group （（0.49±0.65） mm vs. （0.10±0.46） mm, P=0.001）. Percent diameter stenosis at 9-month follow-up was also larger in the zotarolimus-eluting stent group （（30.0±17.9）% vs. （17.6±14.0）%, P 〈0.001）. In-segment analysis showed similar findings. There were no significant differences in binary restenosis rate, major adverse cardiac events, and late-acquired incomplete stent apposition. Conclusions Compared to sirolimus-eluting stents, the zotarolimus-eluting stent is associated with significantly higher in-stent late lumen loss at 9-month angiographic follow-up in the treatment of ST elevation myocardial infarction. Although there was no significant difference in 1-year clinical outcomes, the clinical implication of increased late lumen loss should be further studied.

Practice of reperfusion in patients with ST-segment elevation myocardial infarction in China:findings from the Improving Care for Cardiovascular Disease in China–Acute Coronary Syndrome project

Background:Reperfusion therapy is fundamental for ST-segment elevation myocardial infarction(STEMI).However,the details of contemporary practice and factors associated with reperfusion therapy in China are largely unknown.Therefore,this study aimed to explore reperfusion practice and its associated factors among hospitalized patients with STEMI in China.Methods:Patients with STEMI who were admitted to 159 tertiary hospitals from 30 provinces in China were included in the Improving Care for Cardiovascular Disease in China–Acute Coronary Syndrome project from November 2014 to December 2019.The associations of the characteristics of patients and hospitals with reperfusion were examined using hierarchical logistic regression.The associations between therapies and in-hospital major adverse cardiovascular events were examined with a mixed effects Cox regression model.Results:Among the 59,447 patients,37,485(63.1%)underwent reperfusion,including 4556(7.7%)receiving fibrinolysis and 32,929(55.4%)receiving primary percutaneous coronary intervention(PCI).The reperfusion rate varied across geographical regions(48.0%–73.5%).The overall rate increased from 60.0%to 69.7%from 2014 to 2019,mainly due to an increase in primary PCI within 12 h of symptom onset.Timely PCI,but not fibrinolysis alone,was associated with a decreased risk of inhospital major adverse cardiovascular events compared with no reperfusion,with an adjusted hazard ratio(95%confidence interval)of 0.64(0.54,0.76)for primary PCI at<12 h,0.53(0.37,0.74)for primary PCI at 12 to 24 h,0.46(0.25,0.82)for the pharmaco-invasive strategy,and 0.79(0.54,1.15)for fibrinolysis alone.Conclusions:Nationwide quality improvement initiatives should be strengthened to increase the reperfusion rate and reduce inequality in China.Trial registration:www.ClinicalTrials.gov,NCT02306616。

Intensive care unit adaptations in the COVID-19 pandemic:Lessons learned

The coronavirus disease 2019 pandemic had deleterious effects on the healthcare systems around the world.To increase intensive care units(ICUs)bed capacities,multiple adaptations had to be made to increase surge capacity.In this editorial,we demonstrate the changes made by an ICU of a midwest community hospital in the United States.These changes included moving patients that used to be managed in the ICU to progressive care units,such as patients requiring noninvasive ventilation and high flow nasal cannula,ST-elevation myocardial infarction patients,and post-neurosurgery patients.Additionally,newer tactics were applied to the processes of assessing oxygen supply and demand,patient care rounds,and post-ICU monitoring.