Percutaneous Myocardial Revascularization in Late-Presenting Patients With STEMI

Late presenters with ST-elevation myocardial infarction and thromboembolic complications: a treatment challenge: a case report

BACKGROUND

Late presenters with ST-elevation myocardial infarction pose a considerable challenge in the field of cardiovascular medicine. These individuals, who delay seeking medical attention after the onset of ST-elevation myocardial infarction symptoms, often face substantial difficulties in treatment. The coronavirus disease 2019 pandemic led to a significant increase in the number of late presenters. By increasing the frequency of complications such as thromboembolic events in the course of left ventricular thrombus, the pandemic necessitated the refinement of existing management strategies.

CASE PRESENTATION

In this paper, we present two White male patients of Central European (Polish) descent (50 and 64 years old) who, although reported to have had acute ST-elevation myocardial infarction, turned out to be ST-elevation myocardial infarction latecomers. In both cases, we were dealing with the presence of left ventricular thrombus and complications related to the central nervous system. On the basis of these two patients, we discuss the role of revascularization in latecomer ST-elevation myocardial infarction patients. We present the position of direct oral anticoagulants in the left ventricular thrombus treatment and show that, in limited cases of a huge thrombus, cardiac surgery is a treatment of choice.

CONCLUSIONS

As left ventricular thrombus is still relatively common in ST-elevation myocardial infarction latecomers, we present the current state of knowledge on this topic, emphasizing the need for further research in this area.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

ICU mortality of post-myocardial infarction ventricular septal defect complicated by cardiogenic shock: a retrospective multicentric cohort

PURPOSE

Post myocardial infarction ventricular septal defect (PMI-VSD) complicated by refractory cardiogenic shock is associated with an extremely high mortality rate. We sought to evaluate the factors associated with in-ICU mortality in patients with PMI-VSD-related cardiogenic shock.

METHODS

Patients with PMI-VSD complicated by cardiogenic shock, admitted in 10 French tertiary centers between 2008 and 2022, were retrospectively included. The primary outcome was in-ICU mortality. The timing of surgery was classified as early (≤ 7 days) or late (> 7 days). Multivariable analysis was performed to identify the variables associated with in-ICU mortality.

RESULTS

A total of 138 patients were included (mean age 70 (± 10) years, female sex 54%). Of these, 116 patients (84%) received MCS, including 43 patients (31%) with VA-ECMO. VSD surgical closure was performed in 93 patients (67%, 60 early, 33 late). Only 2 patients had percutaneous closure without surgical repair. A total of 84 patients (61%) died. The type of surgical management strategy was significantly associated with in-ICU mortality (no surgery, 100%; early surgery, 45%; late surgery, 27%; ptrend < 0.001). In all patients, the variables independently associated with in-ICU mortality were: old age (adjusted OR = 1.1, 95%CI [1.02-1.12.], p = 0.004), SOFA score (adjusted OR = 1.2, 95%CI [1.07.-1.37], p = 0.003), and VA-ECMO (adjusted OR = 2.9, 95%CI [1.2-7.7], p = 0.02). In patients with VSD surgical closure, a longer delay between ICU admission and VSD surgical closure was independently associated with decreased in-ICU mortality (adjusted OR = 0.9, 95%CI [0.79-0.96], p = 0.003).

CONCLUSION

Delayed VSD closure is associated with improved outcomes in PMI-VSD complicated by cardiogenic shock.

TRIAL REGISTRATION

#CE SRLF 19-34, #CNIL MR004 2224973, retrospectively registered 04 July 2019.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

State of the Art of Primary PCI: Present and Future

Primary percutaneous coronary intervention (PCI) has revolutionized the management of ST-elevation myocardial infarction (STEMI), markedly improving patient outcomes. Despite technological advancements, pharmacological innovations, and refined interventional techniques, STEMI prognosis remains burdened by a persistent incidence of cardiac death and heart failure (HF), with mortality rates plateauing over the last decade. This review examines current practices in primary PCI, focusing on critical factors influencing patient outcomes. Moreover, it explores future developments, emphasizing the role of microvascular dysfunction-a critical but often under-recognized contributor to adverse outcomes, including incident HF and mortality, and has emerged as a key therapeutic frontier. Strategies aimed at preserving microvascular function, mitigating ischemia-reperfusion injury, and reducing infarct size are discussed as potential avenues for improving STEMI management. By addressing these challenges, the field can advance toward more personalized and effective interventions, potentially breaking the current deadlock in mortality rates and improving longer-term prognosis.

A Common Diagnostic Dilemma: Inflammation or Infarction

Early infarct-associated pericarditis is a rare entity, given the availability of early coronary angiography and intervention. Although the electrocardiogram and the surface echocardiogram are initial studies, definitive imaging with cardiac magnetic resonance is recommended. We present a case of early infarct-associated pericarditis in the setting of a late-presenting silent right coronary artery myocardial infarction.

Percutaneous coronary intervention for stable late ST-elevation myocardial infarction with symptoms onset between 12 and 72 h - A systematic review

BACKGROUND

There exists clinical equipoise regarding whether and when an invasive approach should be preferred over conservative treatment in the management of stable late ST-elevation myocardial infarction (STEMI) presenting within 12 to 72 h of symptom onset.

OBJECTIVE

To perform a systematic review to identify the most effective treatment strategy between percutaneous coronary intervention (PCI) and medical therapy in stable late STEMI presenters by comparing their respective outcomes as well as determine the optimal timing of PCI by evaluating the outcomes of urgent versus non-urgent PCI approach in this patient population.

METHODS

PubMed, Embase, and Cochrane databases were queried from inception until March 2024 for studies comparing the outcomes of PCI versus medical therapy, as well as urgent versus non-urgent PCI, in stable late STEMI patients presenting with symptom onset within 12-72 h. Quality of the studies and risk of bias were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and the Cochrane Risk of Bias (ROBINS-I 2016) tool, respectively.

RESULTS

A total of 8 studies were included in this systematic review that met the inclusion criteria. Among these, 5 studies (1 randomized controlled trial (RCT), 1 post-hoc analysis, and 3 observational studies) with an aggregate of 3820 participants compared PCI and medical therapy in stable late STEMI presenters. They found that PCI was associated with statistically significant better short- and long-term outcomes by lowering all-cause mortality, recurrent myocardial infarction (MI), and infarct size, and by improving myocardial salvage index (P < 0.001). Similarly, a non-statistically significant improvement was seen in the events of cardiac death, heart failure, and revascularization as well as ejection fraction percentage with PCI (P > 0.05). The other 3 studies, involving 1270 participants, were observational and compared urgent versus non-urgent PCI and did not find any statistically significant difference in clinical outcomes between the two approaches (P > 0.05). The included studies were significantly heterogeneous in methodologies, follow-up intervals, and reporting of outcomes. Most of the studies provided moderate quality of evidence and had moderate to serious risk of bias.

CONCLUSIONS AND RELEVANCE

Revascularization through PCI is associated with superior short- and long-term outcomes compared to medical therapy in stable late STEMI patients presenting within 12-72 h of symptom onset. However, the optimal timing of PCI needs further investigation.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) in 2024

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022. Recently, the European Society of Cardiology (ESC) published the guidelines for the management of acute coronary syndrome in 2023. Major new updates in the 2023 ESC guideline include: (1) intravascular imaging should be considered to guide PCI (Class IIa); (2) timing of complete revascularization; (3) antiplatelet therapy in patient with high-bleeding risk. Reflecting rapid advances in the field, the Task Force on Primary PCI of the CVIT group has now proposed an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2024 version.

Characteristics, management and outcome of patients with late-arrival STEMI in the Acute Coronary Syndrome Israeli Surveys (ACSIS)

Introduction

Patients with ST-elevation myocardial infarction (STEMI) and late arrival (>12 h) after symptom onset, are at high risk for mortality and heart failure and represent a challenge for management. We aimed to define patient characteristics, management, and outcome of late-arrival STEMI in Israel over the last 20 years.

Methods

We analyzed data of late-arrival STEMI (12-48 h and > 48 h) from the biennial acute coronary syndrome Israeli Surveys (ACSIS), as well as time-dependent changes [early (2000-2010) Vs. late (2013-2021) period].

Results

Data regarding time from symptom onset to hospital arrival was available in 6,466 STEMI patients. Of these, 9.6 % arrived 12-48 h and 3 % >48 h from symptom onset. Late-arrival patients were more likely to be older women with diabetes and high GRACE score and less likely to have prior myocardial infarction.In recent years, 95 % of patients arriving 12-48 h and 96 % of those arriving > 48 h had coronary angiography, as opposed to 75 % and 77 % in the early years (p = 0.007). Percutaneous coronary intervention (PCI) increased from 60 % and 55 % respectively to 85 % (p ≤ 0.001).TIMI-3 flow after primary PCI was 89-92 %, irrespective of arrival time. Late arrival patients (12-48 h but not > 48 h) who had PCI had better adjusted 1-year survival, HR 0.49 (95 %CI 0.29-0.82), p = 0.01.

Conclusions

Late-arrival STEMI patients have higher risk characteristics. Most late-arrival patients undergo coronary angiography and PCI and have TIMI-3 flow after primary PCI. In patients arriving 12-48 h after symptom onset PCI is associated with better survival.

Type 2 diabetes mellitus in acute myocardial infarction: a persistent significant burden on long-term mortality

Objective

The long-term impact of type 2 diabetes mellitus (T2DM) after an acute myocardial infarction (AMI) has not been thoroughly investigated yet. This study aimed to assess the long-term impact of T2DM after AMI.

Research design and methods

We analyzed the data of three nationwide observational studies from the French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting T2DM were classified as diabetic, and patients presenting type 1 diabetes mellitus were excluded. We identified factors related to all-cause death at 1-year follow-up and divided 1,897 subjects into two groups, paired based on their estimated 1-year probability of death as determined by a logistic regression model.

Results

A total of 9,181 AMI patients were included in the analysis, among them 2,038 (22.2%) had T2DM. Patients with diabetes were significantly older (68.2 ± 12.0 vs. 63.8 ± 14.4, p < 0.001) and had a higher prevalence of a prior history of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or heart failure (22.5% vs. 13.0%, 7.1% vs. 3.1% and 6.7 vs. 3.8% respectively, p < 0.001 for all). Even after matching two groups of 1,897 patients based on propensity score for their 1-year probability of death, diabetes remained associated with long-term mortality, with an HR of 1.30, 95%CI (1.17-1.45), p < 0.001.

Conclusions

T2DM per se has an adverse impact on long-term survival after myocardial infarction. Independently of the risk of short-term mortality, patients with diabetes who survived an AMI have a 30% higher risk of long-term mortality.

Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention?

Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.

Effectiveness of Primary Coronary Intervention for Patients With Delayed ST-Segment Elevation Myocardial Infarction: Insights from Moroccan Cardiology Intensive Care Units

The benefits of myocardial revascularization in ST-segment elevation acute coronary syndrome after 12 to 24 hours from symptom onset remain a topic of debate, especially in patients who are stable and asymptomatic. We analyzed the benefit of late revascularization by primary coronary intervention in patients admitted to Moroccan cardiac intensive care units (CICUs) with ST-segment elevation myocardial infarction after 12 hours of symptom onset. We included a total of 406 patients who met the inclusion criteria: 262 patients in the invasive strategy group and 144 patients in the conservative strategy group. A total of 74.6% were men, and 25.4% were women. For the primary outcome, 46 all-cause deaths were observed at 1 year, with 33 patients in the conservative strategy arm and 13 patients in the invasive strategy group, with a significant difference between the 2 groups (p <0.001). For secondary outcomes, there was no difference in readmission for acute coronary syndrome or acute heart failure between the 2 groups (p = 0.277, p = 0.205). For in-CICU cardiogenic shock and ejection fraction <35% at discharge, more events are observed in the conservative strategy, with a significant difference for both (p <0.001). In multivariable analysis, 1-year all-cause mortality was independently associated with revascularization between 12 and 48 hours (hazard ratio [HR] 0.372, 95% confidence interval [CI] 0.182 to 0.762, p = 0.007), ejection fraction <35% at discharge (HR 1.92, 95% CI 1.22 to 2.54, p = 0.04), and cardiogenic shock in-CICU (HR 2.69, 95% CI 1.82 to 3.78, p = 0.005).Although no evidence exists to date on the true benefit of late primary coronary intervention revascularization in patients with ST-segment elevation myocardial infarction, this practice remains common, as indicated by the results of most registries.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women

AIMS

To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis.

METHODS AND RESULTS

All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased.

CONCLUSION

Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

Effect of delayed hospitalization on patients with non-ST-segment elevation myocardial infarction and complex lesions undergoing successful new-generation drug-eluting stents implantation

In the absence of available data, we evaluated the effects of delayed hospitalization (symptom-to-door time [SDT] ≥ 24 h) on major clinical outcomes after new-generation drug-eluting stent implantation in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and complex lesions. In total, 4373 patients with NSTEMI were divided into complex (n = 2106) and non-complex (n = 2267) groups. The primary outcome was the 3-year rate of major adverse cardiac events (MACE), defined as all-cause death, recurrent MI, and any repeat revascularization. Secondary outcomes included the individual MACE components. In the complex group, all-cause death (adjusted hazard ratio [aHR], 1.752; p = 0.004) and cardiac death (aHR, 1.966; p = 0.010) rates were significantly higher for patients with SDT ≥ 24 h than for those with SDT < 24 h. In the non-complex group, all patients showed similar clinical outcomes. Patients with SDT < 24 h (aHR, 1.323; p = 0.031) and those with SDT ≥ 24 h (aHR, 1.606; p = 0.027) showed significantly higher rates of any repeat revascularization and all-cause death, respectively, in the complex group than in the non-complex group. Thus, in the complex group, delayed hospitalization was associated with higher 3-year mortalities.

Global eligibility and cost effectiveness of icosapent ethyl in primary and secondary cardiovascular prevention

Icosapent ethyl (IPE) is a purified eicosapentaenoic acid-only omega-3 fatty acid that significantly reduced cardiovascular (CV) events in patients receiving statins with established cardiovascular disease (CVD) and those with diabetes and additional risk factors in the pivotal REDUCE-IT trial. Since the publication of REDUCE-IT, there has been global interest in determining IPE eligibility in different patient populations, the proportion of patients who may benefit from IPE, and cost effectiveness of IPE in primary and secondary prevention settings. The aim of this review is to summarize information from eligibility and cost effectiveness studies of IPE to date. A total of sixteen studies were reviewed, involving 2,068,111 patients in the primary or secondary prevention settings worldwide. Up to forty-five percent of patients were eligible for IPE, depending on the selection criteria used (ie, REDUCE-IT criteria, US Food and Drug Administration label, Health Canada label, practice guidelines) and the population studied. Overall, eight cost-effectiveness studies across the United States, Canada, Germany, Israel, and Australia were included in this review and findings indicated that IPE is particularly cost effective in patients with established CVD.

Delayed PCI is not beneficial for STEMI patients with impaired renal function: a retrospective cohort study

BACKGROUND

Preexisting impaired renal function (IRF) and contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) are important prognostic parameters, but it is unknown whether delayed PCI is still beneficial for STEMI patients with IRF.

METHODS

A retrospective single-center cohort study was performed in 164 patients who presented at least 12 h after symptom onset, and were diagnosed with STEMI and IRF. They were assigned to two groups to receive PCI plus optimal medical therapy (OMT) and OMT alone respectively. Clinical outcomes at 30 days and 1 year were compared between two groups, and hazard ratio for survival was analyzed using Cox regression model. A power analysis demanded 34 patients in each group to produce a power of 90% and a P value of 0.05.

RESULTS

The 30-day mortality was significantly lower in PCI group (n = 126) than in non-PCI group (n = 38) (11.1% versus 28.9%, P = 0.018), while there was no significant difference in the 1-year mortality and incidence of cardiovascular comorbidities between the two groups. Cox regression analysis showed that patients with IRF didn't benefit from receiving PCI on survival rate (P = 0.267).

CONCLUSIONS

Delayed PCI is not beneficial on one-year clinical outcomes for STEMI patients with IRF.

Early versus late delayed percutaneous coronary intervention in elderly patients with ST-segment elevation myocardial infarction

BACKGROUND AND OBJECTIVE

There are a substantial proportion of elderly patients with ST-segment elevation myocardial infarction (STEMI) miss the optimal time window (12 h from symptom onset) of primary percutaneous coronary intervention (PCI). For these patients, the ideal timing of delayed PCI remains undetermined. Therefore, this study compared the clinical outcomes of early versus late delayed PCI in elderly patients with STEMI.

METHODS

From January 2014 to September 2019, 512 patients aged ≥ 65 years with STEMI who underwent delayed PCI after 12 h from symptom onset were included and then categorized into the early PCI group (12-48 h, n = 111) and late PCI group (48 h-28 days, n = 401) according to the timing of delayed PCI. Propensity score matching (PSM) was conducted to adjust the confounding factors between groups. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, cardiac death, recurrent myocardial infarction (MI), stroke, and ischemia-driven revascularization.

RESULTS

During a mean follow-up of 77 months, 163 (31.8%) patients developed MACCE and 93 (18.2%) died. Early or late delayed PCI did not make a significant difference in clinical outcomes of MACCE (Before PSM: HR 0.773, 95% CI 0.520-1.149, P = 0.203; After PSM: HR 0.869, 95% CI 0.498-1.517, P = 0.622), all-cause death, cardiac death, recurrent MI, stroke, and ischemia-driven revascularization in both overall patients and the PSM cohorts.

CONCLUSION

Early delayed PCI (12-48 h from symptom onset), for elderly patients with STEMI who present > 12 h after symptom onset is not associated with better long-term clinical outcomes compared with late delayed PCI (48 h-28 days).

Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond

Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.

A comprehensive and longitudinal cardiac magnetic resonance imaging study of the impact of coronary ischemia duration on myocardial damage in a highly translatable animal model

OBJECTIVES

We performed a comprehensive assessment of the effect of myocardial ischemia duration on cardiac structural and functional parameters by serial cardiac magnetic resonance (CMR) and characterized the evolving scar.

BACKGROUND

CMR follow-up on the cardiac impact of time of ischemia in a closed-chest animal model of myocardial infarction with human resemblance is missing.

METHODS

Pigs underwent MI induction by occlusion of the left anterior descending (LAD) coronary artery for 30, 60, 90 or 120 min and then revascularized. Serial CMR was performed on day 3 and day 42 post-MI. CMR measurements were also run in a sham-operated group. Cellular and molecular changes were investigated.

RESULTS

On day 3, cardiac damage and function were similar in sham and pigs subjected to 30 min of ischemia. Cardiac damage (oedema and necrosis) significantly increased from 60 min onwards. Microvascular obstruction was extensively seen in animals with ≥90 min of ischemia and correlated with cardiac damage. A drop in global systolic function and wall motion of the jeopardized segments was seen in pigs subjected to ≥60 min of ischemia. On day 42, scar size and cardiac dysfunction followed the same pattern in the animals subjected to ≥60 min of ischemia. Adverse left ventricular remodelling (worsening of both LV volumes) was only present in animals subjected to 120 min of ischemia. Cardiac fibrosis, myocyte hypertrophy and vessel rarefaction were similar in the infarcted myocardium of pigs subjected to ≥60 min of ischemia. No changes were observed in the remote myocardium.

CONCLUSION

Sixty-minute LAD coronary occlusion already induces cardiac structural and functional alterations with longer ischemic time (120 min) causing adverse LV remodelling.

Frequency and outcomes of STEMI patients presenting between 12 and 24 h after symptom onset: Late-presenting STEMI

OBJECTIVES

To assess the characteristics and prognosis of ST-elevation myocardial infarction (STEMI) patients, presenting between 12 and 24 h after symptom onset, in contemporary regional STEMI systems of care in the United States.

BACKGROUND

Previous observational studies have been inconsistent regarding the benefit of primary percutaneous coronary intervention (PCI) compared with conservative management for late-presenting STEMI patients and the majority of randomized trials are from the fibrinolytic era.

METHODS

Using a two-center registry-based cohort from March 2003 to December 2020, we evaluated the frequency, clinical characteristics, and outcomes of STEMI patients, stratified by symptom onset to balloon time: <3, 3-6, 6-12, and 12-24 h (late presenters).

RESULTS

Among 5427 STEMI patients with available symptom onset time, 6.2% were late presenters, which increased to 11% during the early phase of the Covid-19 pandemic. As symptom onset to balloon time increased, patients were more likely to be older, female, and have a history of hypertension and diabetes mellitus. Late presenters with an identifiable culprit lesion were less likely to be revascularized with PCI (96%, 96%, 95%, and 92%; p for trend = 0.004) and had a longer median door-to-balloon time (82, 109, 107, and 117 min; p for trend < 0.001). In-hospital and 1-year death risks were comparable between late and earlier presenters.

CONCLUSION

Despite the unfavorable risk profile and longer door-to-balloon time, clinical outcomes of late presenters were similar to those presenting within 12 h of symptom onset.

Delayed percutaneous coronary intervention for an extensive iatrogenic left main coronary artery dissection: a case report

BACKGROUND

Iatrogenic left main coronary artery dissection is a rare but serious complication that can occur both during diagnostic coronary angiography and percutaneous coronary intervention. Early diagnosis and choice of optimal management are of crucial importance for patient's outcome while representing a challenge for clinicians.

CASE PRESENTATION

We present a case of iatrogenic left main coronary artery dissection occurring during diagnostic coronary angiography in a 53-year-old Greek woman with a history of coronary artery bypass grafting. Although dissection was greatly extending to mid left anterior descending artery, delayed percutaneous coronary intervention was successfully performed by carefully wiring the true lumen.

CONCLUSIONS

Delayed percutaneous coronary intervention, performed 25 days following the index event, proved to be a feasible and effective strategy for treating a widely extended left main coronary artery iatrogenic dissection.

Management and outcome of post-myocardial infarction ventricular septal rupture-A Low-Middle-Income Country Experience

BACKGROUND

Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients.

METHODS

Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve.

RESULTS

Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%).

CONCLUSION

High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.

A randomized multicenter trial to evaluate early invasive strategy for patients with acute ST-segment elevation myocardial infarction presenting 24-48 hours from symptom onset: Protocol of the RESCUE-MI study

BACKGROUND

For ST-segment elevation myocardial infarction (STEMI) patients presenting 24 to 48 hours from symptom onset, whether early invasive strategy should be performed still remains controversial.

METHODS

This is a prospective, open-label, multicenter, investigator initiated, randomized controlled trial (NCT04962178) to evaluate the efficacy of early invasive strategy for STEMI patients within 24 to 48 hours of symptom onset. A total of 366 patients will be included from 10 hospitals in mainland China. They will be randomly (1:1) divided into 2 groups: the early invasive strategy group (primary percutaneous coronary intervention, PPCI) and conservative strategy group (optimal medical therapy with primary PCI not performed). All patients will be followed for 1 month. The primary end point is myocardial infarction size on cardiac magnetic resonance (CMR). The secondary end points are as follows: (1) major adverse cardiovascular events (MACE), which is defined as a composite of cardiac death, recurrent myocardial infarction, ischemic driven target vessel revascularization and stroke; (2) other CMR end points, including microvascular obstruction, intramyocardial hemorrhage, myocardial area at risk, left ventricular ejection fraction, left ventricular end diastolic volume and left ventricular end systolic volume.

DISCUSSION

This study is designed to evaluate the efficacy of early invasive strategy for STEMI patients within 24 to 48 hours of symptom onset and will add more evidence for clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04962178. Registered on July 14, 2021.

Late Presenters with ST-Elevation Myocardial Infarction: A Call to Action

The emphasis on timely coronary reperfusion in the setting of ST-segment elevation Myocardial Infarction (STEMI) comes from older studies suggesting a significant reduction in mortality among patients treated with fibrinolytic therapy during the first hours after onset of symptoms and a progressive increase in fatal events in those presenting later [...]

Editor-in-Chief's Top Picks From 2021

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Artificial Intelligence & Machine Learning (NEW section), Basic & Translational Research, Biomarkers (NEW section), Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Cardiovascular Disease in Women, Coronary Disease & Interventions, Congenital Heart Disease, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Vascular Medicine, and Valvular Heart Disease.^1-100.