Clinical Characteristics and Outcomes of ST-Elevation Myocardial Infarction in Young Patients: A Single-Center Experience

Objective This study aimed to examine the clinical characteristics, risk factors, and outcomes of patients aged ≤45 years with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Methods From January 2018 to March 2020, this retrospective observational study took place at a tertiary cardiac center in Bahrain. We included patients aged ≤45 years who were admitted with STEMI and had primary percutaneous coronary intervention (pPCI). Results In this study, 510 patients with STEMI receiving pPCI were included, of whom 95 (18%) were younger than 45 years. The young age group had more smokers (57.9% vs. 40.5%, p = 0.003), newly diagnosed dyslipidemia (41.1% vs. 25.5%, p = 0.004), and a positive family history of early coronary artery disease (CAD) (14.7% vs. 4.3%, p = <0.001). Traditional cardiovascular risk factors, such as diabetes mellitus, systemic hypertension, and dyslipidemia, were significantly less common in young patients. Major adverse cardiovascular and cerebrovascular events (MACCE) were also significantly less common in young patients at the one-year follow-up (2.1 vs. 8.4%, p = 0.05). Conclusion Young patients with STEMI are more often smokers with undiagnosed dyslipidemia and have a family history of CAD. MACCE at one year is significantly lower as compared to older patients, but it is not negligible. Public health efforts are needed to reduce the prevalence of modifiable risk factors among the susceptible population.

Optical Coherence Tomography Angiography Changes in Patients Diagnosed With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

We conducted a systematic review and meta-analysis to assess the association between optical coherence tomography angiography (OCTA) parameters and acute coronary syndrome (ACS). Two independent reviewers searched the electronic databases (MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, Embase (Excerpta Medica Database), Cochrane Library, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform) from inception until April 2023. According to the inclusion criteria of this review, eligible were observational studies, randomized control trials, and registry/database studies that included the eyes of adult ACS patients and assessed OCTA parameters within the macula. The pooled standardized mean differences (SMD) between patients diagnosed with ACS and healthy controls with a confidence interval (CI) of 95% were calculated using the Hartung-Knapp-Sidik-Jonkman random-effects method. The heterogeneity was assessed by I2 and the Cochran Q and a random effects model was applied. Seven studies were eligible and included in our systematic review (n = 898), of which three were included in the meta-analysis (n = 341). The pooled SMD in the superficial vascular plexus (SVP), deep vascular plexus (DVP), and foveal avascular zone (FAZ) were -0.46 (95% CI: -0.94 to 0.01, p = 0.05, I2 = 0%, three studies), -0.10 (95% CI: -3.20 to 3.00, p = 0.75, I2 = 67%, two studies), and 0.43 (95% CI: -1.22 to 2.09, p = 0.38, I2 = 92%, three studies), respectively. Our findings suggest that there are no differences in OCTA metrics between ACS patients and healthy individuals.

Reliability of Fractional Flow Reserve in Non-Infarct-Related Arteries in ST-Segment Elevation Myocardial Infarction Patients Undergoing a Pharmaco-Invasive Approach

Objectives We investigated the reproducibility of fractional flow reserve (FFR) of significant stenoses (≥70% narrowing) in the non-infarct related artery (NIRA) during the pharmaco-invasive percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) within 24 hours of thrombolysis and at a follow up of 2-3 weeks. Background STEMI with multivessel disease has worse outcomes. The benefits of FFR-directed PCI of NIRA at the time of primary PCI are yet controversial. Assessing the hemodynamic severity of the NIRA may help in deciding the management strategy of these lesions, save time, and avoid complications. Methods Thirty-one patients undergoing PCI for STEMI under a pharmaco-invasive approach were prospectively recruited. The FFR measurements in 34 stenoses (≥70% diameter stenosis) were obtained immediately after PCI of the culprit stenosis and were repeated at a mean follow-up of 17.6 ± 3.55 (14-21) days. In addition, time to thrombolysis, time from symptom onset to PCI, left ventricular ejection fraction (LVEF), quantitative coronary angiographic measurements of the non-culprit stenoses, and thrombolysis in myocardial infarction (TIMI) flow were recorded. Results There was a significant change in FFR values at follow-up as compared to baseline (0.78 ± 0.08 (0.68-0.93) to 0.77 ± 0.08 (0.67-0.93)) (p = 0.014). In four of the lesions, the FFR values differed by >0.05 at follow-up. The follow-up FFR values led to a change in the management strategy in 5 out of 31 patients (15%) of the lesions. The TIMI flow, percentage diameter stenosis, minimum lumen diameter, and LVEF did not change. There were no predictors of this change in FFR values. Conclusions During the acute phase of STEMI, the severity of non-culprit coronary artery stenoses can not be reliably assessed by FFR. The prolonged jeopardized state of myocardium in pharmaco-invasive PCI as compared to primary PCI seems to be responsible.

A Single Transradial Guiding Catheter in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: A Door-to-Balloon Optimized Strategy

Background Acute coronary syndrome (ACS) is the leading cause of morbidity and mortality worldwide. The different reperfusion strategies have evolved over the years, and efforts have been directed to reduce its complications. Among these strategies, the one that has shown the best results is percutaneous coronary intervention, which has significantly improved the survival and prognosis of these patients; however, this procedure is not free of complications since multiple factors are involved. Among them is the time of patient care from the time of diagnosis until the coronary reperfusion therapy is performed. Methodology In this study, we describe the experience in our center with the 6-French Ikari Left guide catheter as a strategy of radial angiography-angioplasty with a single catheter to reduce the care times of patients with acute ST-elevation myocardial infarction (STEMI) in our center and compare it with the series reported by other international centers since. To establish an alternative to the usual approach that consists of the use of Judkins catheters, diagnosis, and guiding. Results Our study showed a success rate for diagnostic angiography and percutaneous coronary intervention (PCI) with the 6- French Ikari Left catheter comparable to those obtained in other centers, even with lower complication rates than the usual approach with Judkins' Catheters. Conclusions The use of the 6-French Ikari Left catheter demonstrated shorter needle-device time and compared to other international series, it was shown to be shorter and related to shorter fluoroscopy time. Our study has a small sample and only included a highly selected population, which represents a limitation. This study is vulnerable to the different practices of the operators, with involvement in procedure time and use of contrast volume.

Racial Disparities and Outcomes of Percutaneous Coronary Interventions in Patients Above 65 Years in America: A Systematic Review

This systematic review aims to examine the racial disparities and outcomes of percutaneous coronary interventions (PCIs) in patients above 65 years in America. The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020 and includes a comprehensive search strategy, study selection, data extraction, and quality assessment. The search strategy identified 10 relevant articles that were included in the review. The findings indicate that racial disparities exist in access to PCI, door-to-balloon (DTB) time, procedure utilization, and outcomes among elderly patients. African American and Hispanic patients were found to experience longer door-to-balloon time and lower rates of PCI utilization compared to White patients. Moreover, racial and ethnic minorities had worse clinical outcomes, including higher mortality rates and increased risk of major adverse cardiovascular events. The review also highlights the impact of Medicaid expansion on reducing disparities in access, treatment, and outcomes for patients with acute myocardial infarction (AMI). However, limitations in data availability and representation of racial and ethnic minorities in clinical trials were identified. The discussion section provides a robust analysis of the findings, exploring potential underlying factors contributing to the observed disparities. The review concludes that addressing racial disparities in PCI outcomes among elderly patients is crucial for achieving equitable healthcare delivery and improving cardiovascular health outcomes in America.

Shark Fin Electrocardiogram: A Deadly Electrocardiogram Pattern in Takotsubo Cardiomyopathy During 15 Years of Follow-Up

Takotsubo cardiomyopathy (TTC) or stress-induced cardiomyopathy is characterized by transient left ventricular apical ballooning in the absence of coronary occlusion. Although the underlying mechanism is still unknown, exaggerated sympathetic nervous system and catecholamine cardiotoxicity, followed by metabolic disturbance, and multi-vessel epicardial coronary artery vasospasm, are thought to be responsible for the development of this condition. TTC accounts for 1-2% of patients presenting with the acute coronary syndrome (ACS) with the majority of patients being postmenopausal women. Shark fin electrocardiogram (SFE) or triangular ST-segment elevation is an uncommon electrocardiogram (ECG) finding that is typically associated with an increased risk of ventricular fibrillation and cardiogenic shock, thus, it is considered a poor prognostic factor. We present a case of a 57-year-old postmenopausal female with TTC post-colonic perforation. Upon further investigation, an ECG revealed an SFE or triangular ST-segment elevation on the anterolateral leads, and an elevated serum troponin level was found. On trans-thoracic echocardiogram (TTE), hypokinesis and akinesis of the apex and left ventricular segments were observed with sparing of the basal segments. Eventually, the patient was successfully managed and monitored until regain of normal function.

ST-Elevation Myocardial Infarction in a 23-Year-Old Female: The Mystery of Thrombus Formation

Acute ST-elevation myocardial infarction (STEMI) is rarely seen in young adults, however, when encountered, the underlying cause is either a genetic condition leading to early-onset coronary artery disease (CAD), an acquired pro-thrombotic condition, or an idiopathic condition like spontaneous coronary artery dissection (SCAD). Our case describes a healthy 23-year-old female who presented with sudden onset severe angina and was found to have a laminated thrombus in the left anterior descending coronary artery (LAD), with no evidence of intraluminal dissection or plaque rupture. Although the underlying etiology of thrombus formation remains unknown, coronavirus disease 2019 (COVID-19) related thrombotic event is the prime suspect. In addition, another culprit that cannot be excluded is phentermine-induced coronary vasospasm, a commercially available medication for weight loss. This report addresses current literature on acute coronary syndromes in young adults and reviews the potential etiologies for coronary artery thrombosis, which led to a near-fatal acute coronary syndrome in our patient.

Extensive Coronary Thrombosis as a Sequelae of COVID-19 Presenting as a STEMI

Thrombotic complications, in particular ST-elevation myocardial infarction (STEMI), have been described in active Coronavirus disease 2019 (COVID-19) cases. This is a result of systemic inflammation that often leads to endothelial activation, microvascular thrombosis and a hypercoagulable state. However, it is unknown how long patients who have cleared the COVID-19 infection remain at risk for coronary thrombosis as a sequela of disease burden. We present a case of a patient who presented three to four weeks following the initial infection.

Successful Percutaneous Balloon Angioplasty in a Patient Presenting With STEMI and Acute Intracranial Hemorrhage

Percutaneous coronary interventions (PCI) mandates the administration of anti-platelet and anti-thrombotic agents to prevent intracoronary and post-procedural thrombosis upon introducing thrombogenic foreign bodies such as intracoronary wires, balloons, or stents, especially in the setting of acute coronary syndrome (ACS) given the hypercoagulable state associated with it. This is a case of a 54-year-old female who presented to the emergency department with left-sided weakness and dysarthria for an unknown duration. A CT scan of the head showed acute right middle cerebral artery distribution infarct. She subsequently underwent a successful thrombectomy. Four hours later, the patient became lethargic and nauseous. Electrocardiogram showed anterior wall ST elevation with new-onset anterior wall akinesia on transthoracic echocardiogram. Repeat CT of the head showed acute intracranial hemorrhagic conversion. She then developed cardiac arrest mandating emergent cardiac catheterization. Coronary angiogram revealed 100% occlusion in a mid left anterior descending artery (LAD) and 80% in a left circumflex artery (LCX) and chronic total occlusion of the right coronary artery (RCA). After weighing risks and benefits, PCI was performed with rapid plain old balloon angioplasty (POBA) to the 100% thrombotic lesion in the LAD with successful restoration of flow without administering anti-platelet or anti-thrombotic agents given the acute intracranial hemorrhage, She was then discharged to a rehab facility a few days later in stable condition. This case demonstrates successful percutaneous coronary intervention in the 100% occluded LAD in a life-threatening situation despite not using anticoagulation or antiplatelet therapy due to active intracranial hemorrhage.

Metastatic Cardiac Tumor Presenting as an Anteroseptal ST-Segment Elevation Myocardial Infarction in a Young Male

In the appropriate clinical context, ST-segment elevation on electrocardiogram (ECG) necessitates prompt evaluation for coronary artery occlusion requiring reperfusion with percutaneous coronary intervention. Conversely, the etiology of ST-segment elevation may be representative of an alternative diagnosis other than myocardial infarction. We report the case of a patient with a history of primary bone sarcoma who presented for further evaluation of a large pericardial effusion identified on an outpatient echocardiogram and was found to have ST-segment elevation on ECG in the absence of any cardiopulmonary symptoms. The ECG abnormalities were attributed to a likely persistent current of injury resulting from a mass in the interventricular septum, likely representative of a metastatic lesion of his known malignancy. This case highlights the importance of maintaining a broad differential for ST-segment elevation, particularly in patients without symptoms of angina and those with a history of aggressive or relapsing cancer to minimize the morbidity and mortality of invasive procedures.

ST Elevation in a Patient With COVID-19 Infection-Associated Fever: A Case of Brugada Pattern

Coronavirus disease 2019 (COVID-19) is a global pandemic presenting with various cardiovascular manifestations. Although Brugada pattern ST-segment elevation (STE) is well described in patients admitted with febrile illness, the implication of recognizing this abnormality in patients with COVID-19 is critical in providing appropriate care for the patient and also reducing the exposure of healthcare professionals to the risk of infection. We report a patient with COVID-19 infection presenting with STE due to fever-related unmasking of Brugada pattern, who was managed conservatively.

Effect of multiple clinical factors on recurrent angina after percutaneous coronary intervention: A retrospective study from 398 ST-segment elevation myocardial infarction patients

Recurrent angina (RA) has an important influence on health status of patients after percutaneous coronary intervention (PCI). This study aimed to retrospectively investigate the effect of multiple clinical factors on both short-term and long-term development of RA.A total of 398 ST-segment elevation myocardial infarction (STEMI) patients were studied for up to 12 months. The primary clinical outcome, RA, was assessed at 1-month and 12-month. In multivariate analyses, the effect of clinical factors, including baseline demographics, medical history, infarction-related arteries, procedural characteristics of PCI, and the use of medicines, was investigated in patients with and without RA.The Logistic regression analysis showed that the patients with treatment through radial approach PCI (odds ratio [OR]: 0.42, 95% confidence interval [CI]: 0.18-0.96, P < 0.05) were less likely to have RA during 1-month assessment. During 12 months after PCI, male patients (OR: 0.53, 95% CI: 0.29-0.96, P < 0.05), and/or those treated with radial approach PCI (OR: 0.45, 95% CI: 0.21-0.97, P < 0.05) were less likely to have RA, whereas the patients with infarction related artery (IRA) in left anterior descending (LAD) (OR: 2.41, 95% CI: 1.20-4.84, P < 0.01) were more likely to have RA at follow-up. The Cox regression analysis further revealed that the patients with infarction of the LAD artery (hazard ratio [HR]: 2.08, 95% CI: 1.10-3.92, P < 0.05), but not with treatment through radial artery during PCI (HR: 0.42, 95% CI: 0.18-0.96, P < 0.05) had higher potential of development of RA during 12 months after PCI.We studied the effects of multiple clinical factors on the development of RA after PCI. Our findings suggest that patients with infarction of the LAD artery, and/or treatment not through radial artery during PCI were associated with higher risk of RA and may require close follow-up.