Relationship Between C-Reactive Protein to Albumin Ratio and Infarct-Related Artery Patency in Patients With ST-Segment Elevation Myocardial Infarction

The C-reactive protein to albumin ratio (CAR) is a predictive marker of systemic inflammatory state in atherosclerotic coronary disease when compared with the predictive value of these 2 markers separately. We investigated the relationship between CAR and infarct-related artery (IRA) patency in patients with ST-segment elevation myocardial infarction (STEMI). The study population (n = 1047) was divided into 2 groups according to IRA patency which was assessed by the Thrombolysis in Myocardial Infarction (TIMI) flow grade. Nonpatent flow was defined as TIMI grade 0 (no-reflow), 1, and 2 flows, and normal flow was defined as TIMI 3 flow. There was a significant positive correlation between CAR and SYNTAX score ( r = 0.312, P < .001) and a negative correlation between CAR and TIMI grade flow ( r = −0.210, P < .001). At a cutoff level of 0.693, the CAR predicted TIMI no-reflow with a sensitivity of 65.4% and a specificity of 65.5% (area under the curve: 0.670, 95% CI: 0.62-0.71, P < .001). Multivariate logistic regression analyses showed that CAR was an independent predictor of IRA patency (0.003 [0.001-0.029]; P < .001). A higher CAR is a significant and independent predictor of IRA patency in patients with STEMI.

Coronary angioplasty and COVID-19: are heparin requirements and thrombotic complications increasing?

Funding Acknowledgements Type of funding sources: None. Background Covid-19 infection is associated with coagulopathy and possible heparin resistance, raising concerns that routine heparin during percutaneous coronary intervention (PCI) is failing to achieve adequate anticoagulation. We examined heparin requirements and efficacy in patients treated by PCI before and after the first reported UK case of Covid-19 (January 31st 2020). Methods We retrospectively compared heparin dose, Activated Clotting Time (ACT) and coronary flow (TIMI grade) for PCI procedures at a London cardiac centre in the 3 months before the UK pandemic and the three months afterwards. Testing for COVID was not routinely performed. Pre-specified analyses in patients with STEMI, NSTEMI and Stable angina were undertaken. Results Of 1227 PCI procedures performed over the period of observation, 690 were pre-pandemic and 537 were afterwards. Overall median heparin dose per case was 11000units versus 11500units (p = 0.137) and maximum ACTs were 291s versus 305s, respectively (p = 0.135). Pre-PCI TIMI 3 flow was lower during the pandemic than before (60% v 65%, p = 0.005) but Post-PCI flow was similar (96% versus 96%, p = 0.839). There were no statistically significant differences in heparin dose or achieved ACT among patients with STEMI, NSTEMI or Stable presentations. Conclusion In spite of the increasing evidence that COVID-19 infection causes thrombosis, it appears that standard heparin management during PCI is sufficient to achieve effective anticoagulation and avoid peri-procedural thrombotic complications. Group 1 Pre PandemicGroup 2 PandemicP valueNumber of doses given3 (3 to 4)3 (3 to 4)0.952Total Heparin dose (units)11000 (8000 to 14000)11500 (9000 to 14000)0.137Number of ACTs measured2 (1 to 2)2 (1 to 2)0.194First ACT (seconds)240 (199 to 318)248 (206 to 326)0.256Maximum ACT (seconds)291 (230 to 368)305 (239 to 369)0.135Heparin dose and Activated Clotting Times (ACT) in patients undergoing PCI before Covid-19 pandemic (Group 1) and during pandemic (Group 2); median and interquartile rangesAbstract Figure. Clinical Presentation

Performance Analysis of a Novel Hydrophilic-Coated Transradial Guiding Catheter

Aim: The transradial approach (TRA) has taken an upswing, however access-site complications still exist. The choice of potentially less traumatic materials may minimize these complications. This article describes the use of a hydrophilic-coated 6F guiding catheter for diagnostic and interventional procedures and upper extremity dysfunction following these procedures. Materials and Methods: This prospective observational study enrolled 217 patients who underwent elective transradial percutaneous coronary intervention (TR-PCI) for stable and unstable angina, or acute coronary syndrome between May 2014 and November 2016. All patients were treated using a 6F hydrophilic-coated guiding catheter (PRIMUM, PendraCare, Wellinq, the Netherlands). Catheter performance was assessed on a five-point scale ranging from very bad to very good. Procedure safety was assessed using the Major cardiac and cerebrovascular events (MACCE) criteria. Results: The average number of guiding catheters used was 1.2 per patient. Overall performance of the catheters was rated Average/Good. Procedural success, defined as TIMI grade 3 flow and successful stent deployment, with a residual diameter stenosis of <25%, was 97.7%. MACCE occurred in 1.5% during the 6-months of follow-up. Conclusion: These data indicate that the use of a hydrophilic-coated guiding catheter to perform percutaneous coronary interventions is safe and effective, with high procedural success and low complication rates. In addition, the short and long-term MACCE outcomes of the PCI were favorable.

The impact of emergent PCI on clinical outcome in AMI patients with out-of-hospital cardiac arrest: the Yamagata AMI registry

Background Despite improvement of survival rate in acute myocardial infarction (AMI), out-of-hospital cardiac arrest (OHCA) is still devasting condition. The association of emergent percutaneous coronary intervention (PCI) with clinical outcome in AMI patients with OHCA has not yet been fully elucidated. Purpose The purpose of the present study was to examine the impact of emergent PCI on the clinical outcome in AMI patients with OHCA. Method and results We analyzed the data from Yamagata AMI registry among 2012–2017, which is multicenter surveillance conducted in all institution on Yamagata prefecture. Among 3332 AMI patients, there were 254 AMI patients with OHCA. The acute death rate was higher in AMI patients with OHCA than those without (70% vs. 13%, P&lt;0.0001). Successful PCI was defined as TIMI grade flow III. AMI patients with OHCA were divided into three groups based on the PCI (successful PCI group, n=70; unsuccessful PCI group, n=14; and Non-PCI group, n=170). The acute death rates in successful PCI, unsuccessful PCI, and non-PCI group were 13%, 64%, 94%, respectively. Kaplan-Meier analysis demonstrated that acute death rate was the lowest in successful PCI group compared to other groups. Multivariate Cox proportional hazard regression analysis demonstrated that successful PCI was inversely associated with acute death after adjustment for confounding factors. The rate of thrombus aspiration was higher in successful PCI than in unsuccessful PCI group. Conclusion Successful PCI is of critical importance to prevent acute death in AMI patients with OHCA. Funding Acknowledgement Type of funding source: None

Predictors of in-hospital mortality in patients with acute myocardial infarction due to unprotected left main trunk lesion: insight from the Tokyo Cardiovascular Care Unit network multicenter registry

Background Acute myocardial infarction (AMI) due to unprotected left main trunk (LMT) lesion remains a clinical challenge because it requires prompt and efficient revascularization in catastrophic clinical presentation. However, predictors of in-hospital prognosis in patients with LMT-AMI are still not fully understood. Purpose To examine the predictors of in-hospital mortality in patients with LMT-AMI. Methods From 20,257 AMI patients in the Tokyo Cardiovascular Care Unit network registry (comprising 72 hospitals) from 2013 to 2017, we identified 371 (1.8%) eligible LMT-AMI patients without a history of coronary artery bypass grafting (CABG) and divided them into two groups: 254 survivors and 117 non-survivors. Measured variables included patient demographics, vital signs, laboratory data on admission, and in-hospital treatment. The outcome was in-hospital mortality. We performed a multivariable logistic regression analysis for in-hospital mortality with adjustment for the following 9 potential confounders, based on previous studies: (1) age, (2) sex, (3) Killip class, (4) ST elevation, (5) wide QRS (&gt;120 msec), (6) the Thrombolysis in Myocardial Infarction (TIMI) grade on initial coronary angiography, (7) number of vessels with significant stenosis other than LMT, (8) renal dysfunction on admission, and (9) plasma glucose on admission. Results Overall, mean age was 70.6±11.8 years and 81.9% were male. ST-elevation myocardial infarction accounted for 61.8%. Cardiac arrest was observed in 102 (33.6%) patients. Percutaneous coronary intervention and CABG were performed in 302 (81.8%) and 63 (17.0%) patients, respectively. Intra-aortic balloon pumping and veno-arterial extracorporeal membranous oxygenation were used in 288 (77.8%) and 81 (21.9%) patients, respectively. In-hospital mortality was 31.5%. Multivariable logistic regression analysis showed that higher in-hospital mortality was significantly associated with Killip class IV (adjusted odds ratio 3.41 [95% confidence interval 1.36–8.56]; reference: Killip I), TIMI grade 0 (3.51 [1.22–10.14]; reference: TIMI grade 3), renal dysfunction (estimated glomerular filtration &lt;60 mL/min/1.73m2; 6.48 [2.53–16.57]), and high plasma glucose on admission (&gt;150 mg/dl; 3.64 [1.33–9.97]). Age, sex, ST-elevation, wide QRS, and multi-vessel disease were not significantly associated with in-hospital mortality. Conclusions LMT-AMI remains life-threatening in the current era of widely available revascularization. Our results showed that haemodynamic compromise, no coronary flow, renal dysfunction, and high plasma glucose on admission were strong predictors of in-hospital mortality after LMT-AMI. Given the high cardiac arrest rate, more aggressive therapeutic measures including mechanical circulatory support may be required to improve the prognosis of LMT-AMI. Funding Acknowledgement Type of funding source: None

Association of microRNA-224 and microRNA-155 expressions with coronary microvascular obstruction following primary angioplasty for acute ST-segment elevation myocardial infarction

Background Proinflammatory stimuli induce a variety set of microRNAs (miRs) expressions in human mononuclear cells that regulate long pentraxin-3 (PTX3) gene, which associates with a procoagulant state in the endothelial cells. Purpose We evaluated, for the first time, the association of miR-224 and miR-155 expressions with coronary microvascular obstruction (MVO) and plasma PTX3 concentration in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty. Methods The expression levels of miR-224 and miR-155 on admission were evaluated in 217 consecutive patients with STEMI (symptom onset &lt;12h) undergoing primary angioplasty between January 2018 and August 2018, and results were analyzed by the median values. The miRs expression and plasma PTX3 concentration were measured by TaqMan real-time PCR and human ELISA kit, respectively. The primary outcome of the study was the occurrence of angiographic MVO, defined as a post-primary angioplasty TIMI grade &lt;3 flow or TIMI grade 3 flow with myocardial blush grade 0 or 1. Results After adjustment with sex, age and plasma PTX3 concentration, miR-244 ≥ median group was associated with angiographic MVO (odds ratio, 2.81; 95% confidence interval 1.34 to 5.92, p=0.006). Spearman analysis showed no correlations between miR-224 and miR-155 expressions with plasma PTX3 concentration. Conclusion This study suggests that miR-224 expression, (but not miR-155), associates with angiographic MVO following primary angioplasty for STEMI. However, miR-224 and miR-155 expressions did not correlate with plasma PTX3 concentration. Future studies are needed to find the molecular inflammatory pathway related with miR-224 expression in MVO. Funding Acknowledgement Type of funding source: None

Differential Diagnosis, Clinical Characteristics, and Interventions of Braid-Like Coronary Artery: Case Series Analysis Based on Optical Coherence Tomography

Aim. Based on optical coherence tomography (OCT), we aimed to determine the diagnosis, clinical characteristics, and interventions of braid-like coronary arteries, which are rare and tend to be diagnosed as a woven coronary artery (WCA) anomaly. Methods and Results. We identified braid-like lesions on coronary angiography (CAG) in 7 patients (6 men; median age 47 years; age range 26 to 57 years). All patients were heavy smokers. Four patients were diagnosed with an old myocardial infarction and the other 3 with unstable angina. The braid-like lesions were located in the left anterior descending arteries in 2 patients and in the right coronary arteries in the other 5. TIMI grade 2 flow was observed in all involved vessels. OCT findings of all lesions were consistent with recanalization of organized thrombi, which consisted of septa that divided the lumen into multiple small cavities communicating with each other. No separate three-layered structure could be defined. Based on the significance of the stenosis and its related symptoms, drug-eluting stents were implanted in all of the lesions. All patients experienced symptomatic improvement after the intervention and were followed up event-free for 12 months. Conclusions. Braid-like coronary arteries are likely to undergo recanalization of organized thrombi rather than WCA according to our OCT findings. The majority of cases affect men who smoke heavily. Percutaneous stent implantation may be beneficial in selected patients when feasible.

The diagonal branches and outcomes inpatients with anterior ST- elevation myocardial infarction

Background: The management of diagonal branch (D) occlusion is still controversary. The association between the flow loss of D and the prognosis remains unclear. We aim to detect the impact of D flow on cardiac function and clinical outcomes in patients with anterior ST-segment elevation myocardial infarction (STEMI). Methods: Patients with anterior STEMI undergoing primary percutaneous coronary intervention (PCI)at our clinic between October 2015 and October 2018were reviewed. Anterior STEMI due to left anterior descending artery (LAD) occlusion with or without loss of the main D flow (TIMI grade 0-1 or 2-3) was enrolled in the analysis. The short- and long-term incidence of major adverse cardiac events (MACEs, a composite of all-cause death, target vessel revascularization and reinfarction) and left ventricular ejection fraction (LVEF) were analyzed. Results: A total of 392 patients (mean age of 63.9years) with anterior STEMI treated with primary PCI was enrolled in the study. They were divided into two groups, loss (TIMI grade 0-1, n=69) and no loss (TIMI grade2-3, n=323) of D flow, before primary PCI. Compared with the group without loss of D flow, the group with loss of D flow showed a lower LVEF post PCI (41.0% vs. 48.8%, p=0.003). Meanwhile, loss of D flow resulted in the higher in-hospital, one-month, and 18-month incidence of MACEs, especially in all-cause mortality (all p<0.05). Landmark analysis further indicated that the significant differences in 18-month outcomes between the two groups mainly resulted from the differences during the hospitalization. In addition, multivariate Cox proportional hazards analysis found that D flow loss before primary PCI was independent factor predicting short- and long-term outcomes in patients with anterior STEMI. Conclusion: Loss of the main D flow in anterior STEMI patients was independently associated with the higher in-hospital incidences of MACEs and all-cause death as well as the lower LVEF.