Preinfarction angina: clinical significance and relationship with total ischemic time in patients with ST-elevation myocardial infarction

The impact of preinfarct angina on the incidence of acute kidney injury in patients with myocardial infarction: interaction with pre-existent chronic kidney disease

AIM

Remote ischemic conditioning may reduce acute kidney injury (AKI) in patients undergoing a coronary intervention. As preinfarct angina (PIA) might act as a preconditioning stimulus in patients with ST-elevation myocardial infarction (STEMI), we aimed to study whether PIA reduces AKI in accordance to pre-existing chronic kidney disease.

PATIENTS AND METHODS

We conducted a retrospective study including 891 consecutive STEMI patients who underwent primary coronary intervention from January 2008 to March 2016. AKI was determined on the basis of KDIGO criteria. The impact of PIA was evaluated in three groups according to the baseline glomerular filtration rate: less than 45 ml/min/1.73 m (group 1, n = 89), 45-59 ml/min/1.73 m (group 2, n = 117), and greater than or equal to 60 ml/min/1.73 m (group 3, n = 642). Univariate and multivariate predictors for AKI were determined.

RESULTS

AKI developed in 13.8% of patients (n = 117) and was more prevalent in patients with worse baseline renal function (35% in group 1; 22% in group 2; and 9% in group 3, P < 0.01). The prevalence of PIA was similar across groups (28-34%, P = 0.2). Only in group 1 did patients with PIA have a significantly lower rate of AKI than patients without PIA (19 vs. 42%, P = 0.033). In multivariate analysis, the absence of PIA in group 1 patients conferred an almost three-fold risk of developing AKI (odds ratio = 2.92, P = 0.009), whereas no differences were found for the other groups. Age, total ischemic time, and intra-aortic balloon pump utilization were also related independently to AKI.

CONCLUSION

In our series, STEMI patients with at least stage 3B chronic kidney disease had a three-fold risk of developing AKI in the absence of PIA. These findings suggest that patients with worse renal function may be more susceptible to the renoprotective effect of myocardial ischemic preconditioning.

The Value of Pre-Infarction Angina and Plasma D-Dimer in Predicting No-Reflow After Primary Percutaneous Coronary Intervention in ST-Segment Elevation Acute Myocardial Infarction Patients

Background

Primary percutaneous coronary intervention (PCI) has improved outcomes greatly in patients with ST-elevation myocardial acute infarction (STEMI). However, the no-reflow phenomenon significantly reduces its efficacy.

Material/Methods

In this study, we investigated the value of combining plasma D-dimer level on admission and pre-infarction angina (PIA) in predicting no-reflow phenomenon in STEMI patients after primary PCI. A total of 926 STEMI patients who underwent primary PCI were included.

Results

The average age was 52.6 years, 617 (66.6%) of them had experienced a PIA, and 435 (47.9%) showed no-reflow phenomenon after primary PCI. Both PIA and plasma D-dimer on admission were independent predictors of no-reflow, with a risk of 0.516 (95% CI: 0.380 to 0.701) and 2.563 (95% CI: 1.910 to 3.439), respectively. Plasma D-dimer level had an area under curve (AUC) of 0.604 (95% CI: 0.568~0.641) in predicting no-reflow phenomenon, and PIA had an AUC of 0.574 (95% CI: 0.537 to 0.611). Importantly, the new signature combining D-dimer level on admission and PIA showed an increased AUC (0.637, 95%CI: 0.601 to 0.673) in predicting the no-reflow phenomenon. Moreover, the patients with high D-dimer level on admission but without PIA had significantly increased ratio of no-reflow phenomenon and in-hospital mortality compared to the other patients (P<0.001 and P=0.041, respectively).

Conclusions

Based on these solid results, we conclude that combining plasma D-dimer level on admission and PIA might create a good signature for use in predicting the no-reflow phenomenon after primary PCI in STEMI patients.

Lack of Benefit of Ischemic Postconditioning After Routine Thrombus Aspiration During Reperfusion

Objectives:

The underutilization of manual thrombus aspiration (MTA) may have reduced the benefits of ischemic postconditioning (PostCon), as it reduces thrombus embolization. We aimed to assess the benefits of PostCon in patients with ST-segment elevation myocardial infarction (STEMI) after the systematic utilization of MTA.

Methods:

A total of 87 patients were enrolled in a prospective, randomized trial (43 PostCon and 44 controls). After MTA, PostCon was performed on the treatment group by applying 4 cycles of alternate reperfusion and reocclusion (60 seconds each) using the angioplasty balloon. The primary end point was infarct size assessed by the area under the curve (AUC) of troponin T (TnT) activity. The secondary end points were left ventricle ejection fraction (LVEF) and major cardiac events (new myocardial infarction or cardiac death) both at discharge and at follow-up.

Results:

The AUC for TnT was no different with respect to study arms (median [interquartile range]): PostCon = 8.9 (10.6) versus control = 8.2 (10.6), P = .68. Left ventricle ejection fraction improved from in-hospital to follow-up (9 ± 3 months) for the entire cohort (46.3% ± 7.3% vs 52.2% ± 10.7%, P < .001), with no differences between PostCon and controls (51.6% ± 9.5% vs 52.7% ± 11.9%, P = .89); major cardiac events at 14 ± 4 months of follow-up were also no different (PostCon = 1.0 (2.3%) vs control = 0, P = .49).

Conclusion:

In patients with STEMI treated with MTA, PostCon offered no benefits to infarct size, LVEF, or major cardiac events.