Angiographic characteristics and in hospital outcome of young patients, age up to 40 versus more than 40 years undergoing primary percutaneous coronary intervention.

OBJECTIVE: To compare angiographic characteristics and outcomes of primary percutaneous coronary intervention between young and old patients presenting with acute ST Elevation Myocardial Infarction. METHODS: The prospective observational study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from December 17, 2016, to June 16, 2017, and comprised acute ST-Elevation Myocardial Infarction patients undergoing primary percutaneous coronary intervention (PCI). Data was collected on demographic, angiographic, and in-hospital outcomes. Those <40 years were considered young. Data was analysed using SPSS 21. RESULTS: Of the 415 patients, 50(12%) were young. Proportion of male was higher among the young (p=0.02) and so was the case with positive family history (p=0.002). The young had lesser cases of diabetes (p=0.028) and hypertension (p=0.034). Single vessel disease was more common among young (p<0.001). No significant difference was observed in post-procedure outcome related to age (p>0.05). CONCLUSIONS: Acute Myocardial Infarction in young was more likely associated with male gender, positive family history and less likely with hypertensive and diabetic status.

Immediate in-hospital outcomes after percutaneous revascularization of acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) is a life-threatening complication of acute myocardial infarction with high morbidity and mortality rates. Primary percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with CS. AIM: To investigate the immediate mortality rates in patients with CS undergoing primary PCI and identify mortality predictors. METHODS: We conducted a retrospective analysis of 305 patients with CS who underwent primary PCI at the National Institute of Cardiovascular Diseases, Karachi, Pakistan, between January 2018 and December 2022. The primary outcome was immediate mortality, defined as mortality within index hospitalization. Univariate and multivariate logistic regression analyses were performed to identify predictors of immediate mortality. RESULTS: In a sample of 305 patients with 72.8% male patients and a mean age of 58.1 ± 11.8 years, the immediate mortality rate was found to be 54.8% (167). Multivariable analysis identified Killip class IV at presentation [odds ratio (OR): 2.0; 95% confidence interval (CI): 1.2-3.4; P = 0.008], Multivessel disease (OR: 3.5; 95%CI: 1.8-6.9; P < 0.001), and high thrombus burden (OR: 2.6; 95%CI: 1.4-4.9; P = 0.003) as independent predictors of immediate mortality. CONCLUSION: Immediate mortality rate in patients with CS undergoing primary PCI remains high despite advances in treatment strategies. Killip class IV at presentation, multivessel disease, and high thrombus burden (grade ≥ 4) were identified as independent predictors of immediate mortality. These findings underscore the need for aggressive management and close monitoring of patients with CS undergoing primary PCI, particularly in those with these high-risk characteristics.

Left Ventricular Functional Remodeling after Primary Percutaneous Coronary Intervention.

Background: Improvement in left ventricular (LV) function after revascularization is an important determinant of long-term prognosis in a patient with acute myocardial infarction (AMI). However, data on the changes of LV function after revascularization are scarce in our population. Hence, this study was conducted to evaluate the changes in LV function and dimensions by echocardiography at 3 and 6 months after primary percutaneous coronary intervention (PCI). Materials and Methods: A total of 188 patients were recruited in this study who had undergone primary PCI. Patients with preexistent LV dysfunction, prior PCI, or with congenital heart disease were excluded. Echocardiography was performed at baseline (within 24 h of intervention), 3 months, and 6 months of intervention. Remodeling in terms of change in LV ejection fraction (LVEF), LV end-diastolic dimension (LVEDD), LV end-systolic dimension, and wall motion score index (WMSI) was evaluated. Results: Out of the 188 patients, 90.4% were male, and mean age was 53.94 ± 9.12 years. Baseline mean LVEF was 39.79 ± 6.2% with mean improvement of 5.11 ± 3.87 (P < 0.001) at 3 months and 6.38 ± 4.29 (P < 0.001) at 6 months. Baseline LVEDD was 46.23 ± 3.86 mm which improved to 44.68 ± 2.81 mm at 6 months. Basal WMSI decreased by -0.09 ± 0.08 and -0.13 ± 0.09 at 3 and 6 months, respectively, after revascularization. Conclusions: Primary PCI is the recommended mode of reperfusion in patients with AMI. It reduces infarct size, maintains microvascular integrity and preserves LV systolic function hence improving LV function.

CHA2DS2-VASc, a Simple Clinical Score Expanding Its Boundaries to Predict Contrast-Induced Acute Kidney Injury After Primary Percutaneous Coronary Interventions.

OBJECTIVE: Promising results of CHA2DS2-VASc score have been reported for the prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, data of its predictive strength in the context of primary PCI are not available. Therefore, in this study, we have assessed predictive value of CHA2DS2-VASc score for CI-AKI after primary PCI. METHODS: This analytical cross-sectional study was conducted between January 2021 and June 2021 at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Inclusion criteria of the study was consecutive adult patients who had undergone primary PCI. Baseline CHA2DS2-VASc score was calculated, and either a 25% or 0.5 mg/dL increase in post-procedure serum creatinine level as compared to baseline level was categorized as CI-AKI. RESULTS: A total of 691 patients were included, of which 82.1% (567) were male. CI-AKI after primary PCI was observed in 63 (9.1%) patients, out of which 66.7% (42) of patients had CHA2DS2-VASc score of ≥2. The area under the curve (AUC) for the score was 0.725 [0.662 to 0.788] with a sensitivity and specificity of 66.7% [63.1% to 70.2%] and 66.7% [53.7% to 78.1%], respectively, at a cut-off value of ≥2. In multivariable analysis, left ventricular ejection fraction ≤30% and CHA2DS2-VASc ≥2 were found to be independent predictors with adjusted odds ratios of 2.19 [1.06-4.5] and 2.13 [1.13-4.01], respectively. CONCLUSION: CHA2DS2-VASc score has a good predictive value for the prediction of CI-AKI after primary PCI. Criteria of CHA2DS2-VASc ≥2 can be used for the risk stratification of CI-AKI after primary PCI.

Zwolle Risk Score for Safety Assessment of Same-day Discharge after Primary Percutaneous Coronary Intervention.

OBJECTIVES: The Zwolle risk score (ZRS) has been considered to be a useful tool for the systematic evaluation of patients for early discharge after primary percutaneous coronary intervention (PCI). Therefore, aim of this study was to evaluate the clinical utility of ZRS for the same-day discharge strategy after primary PCI at a tertiary care cardiac center of Karachi, Pakistan. METHODS: This study was conducted at a tertiary care cardiac center between August 2019 and July 2020. Patients discharged within 24 h (same-day) of the primary PCI procedure were included. Patients were stratified as high- and low-risk based on ZRS score; low-risk (≤3) and high-risk (≥4). All patients were followed during 30-days post-procedure period for major adverse cardiac events (MACE). RESULTS: Out of 487 patients, 83.2% (405) were male and mean age was 54.6 ± 10.87 years. Mean ZRS was 2.34 ± 1.64 with 16.0% (78) patients in high-risk (≥4) group. 30-days MACE rate was observed to be 5.3% (26) with significantly higher rate among high-risk patients as compared to low-risk patients 12.8% (10) vs. 3.9% (16); p = 0.004 respectively with OR of 3.61 [1.57-8.29]. The area under the curve (AUC) of ZRS for prediction of 30-day MACE was 0.67 [95% CI: 0.58-0.77], ZRS ≥4 had sensitivity of 38.5% and specificity of 85.2% with AUC of 0.62 [95% CI: 0.50-0.74] for prediction of 30-day MACE. CONCLUSION: ZRS showed moderate discriminating potential in identifying patients with high-risk of MACE at 30-day after same-day discharge after primary PCI.

Validity of the Stent Thrombosis Risk Score in Predicting Early Stent Thrombosis after Primary Percutaneous Coronary Intervention.

BACKGROUND: The thrombosis of the stent is one of the most important complications of percutaneous interventions, resulting in complete occlusion of the stented vessel. Aim of this study was to determine the validity of Stent Thrombosis Risk Score (STRS) in predicting early stent thrombosis (ST) after primary Percutaneous Coronary Intervention (PCI). METHODS: For this study, 569 consecutive patients undergone primary PCI from July 2018 to December 2018 were recruited. Early ST was defined as ST occurred during or within 30 days after the procedure. The STRS was calculated as proposed, developed, and validated in a past study. The receiver operating characteristic curve analysis was performed to determine the optimal cut-off value and area under the curve (AUC). RESULTS: A total of 569 patients were included, the median age was 56 [61-50] years. Early ST was observed in 33 (5.8%) patients. The median STRS was 4 [5-3] vs. 3 [4-2]; p = 0.009 for patients with and without Early ST respectively. STRS was found to be an independent predictor of early ST with an adjusted odds ratio of 1.41 (1.02-1.95). AUC was 0.631 and the optimal cut-off value was ≥5. Early ST rate was 3.3% at STRS of 0-2, which raised to 5.0% at STR of 3-4, and 17.2% at STRS of ≥5. CONCLUSIONS: In conclusion, STRS was found to be an independent predictor of early ST after primary PCI and has significant discriminating power. The rate of early stent thrombosis after primary PCI exponentially increased at STRS cut-off value of ≥5.

Radial or femoral access in primary percutaneous coronary intervention (PCI): Does the choice matters?

BACKGROUND: This study was conducted with the aim of providing a quantitative appraisal of clinical outcomes of trans-radial access for primary percutaneous coronary interventions (PCI) in patients with ST-segment evaluation myocardial infarction (STEMI). METHODS: In this study, we compared two propensity-matched cohorts of patients who underwent primary PCI via trans-radial (TRA) and trans-femoral access (TFA) in a 1:1 ratio. The profile of two cohorts was matched for gender, age, and body mass index, diabetes, hypertension, family history, and smoking. The outcomes of primary PCI were compared for the two cohorts which included all-cause in-hospital mortality, heart failure, re-infarction, cardiogenic shock, bleeding, transfusion, cerebrovascular accident, and dialysis. RESULTS: This analysis was performed on a total of 2316 patients with 1158 patients each in the TRA and TFA group. We observed significantly lower rates of mortality, 0.8% (9) vs. 3.5% (41); p < 0.001 and bleeding, 0.5% (6) vs.1.6% (19); p = 0.009 with shorter hospital stay, 1.61 ± 1.39 vs. 1.98 ± 1.5 days, in trans-radial vs. trans-femoral. However, both fluoroscopic time and contrast volume were significantly higher in the TRA as compared to TFA group 15.57 ± 8.16 vs. 12.79 ± 7.82 min; p < 0.001 and 143.22 ± 45.33 vs. 133.78 ± 45.97; p < 0.001 respectively. CONCLUSIONS: Compared with TFA access, TRA for primary PCI is safe for patients with STEMI, it was found to be associated with a significant reduction in in-hospital mortality and bleeding complications.

Assessment of electrocardiographic criteria of left atrial enlargement.

Background Left atrial enlargement is considered to be a robust, strong, and widely acceptable indicator of cardiovascular outcomes. Echocardiography is the gold standard for measurement of left atrial size, but electrocardiography can be simple, cost-effective, and noninvasive in clinical practice. This study was undertaken to assess the diagnostic accuracy of an established electrocardiographic criterion for left atrial enlargement, taking 2-dimensional echocardiography as the gold-standard technique. Methods A cross-sectional study was conducted on 146 consecutively selected patients with the complaints of dyspnea and palpitation and with a murmur detected on clinical examination, from September 10, 2016 to February 10, 2017. Electrocardiography and echocardiography were performed in all patients. Patients with a negative P wave terminal force in lead V1 > 40 ms·mm on electrocardiography or left atrial dimension > 40 mm on echocardiography were classified as having left atrial enlargement. Sensitivity and specificity were calculated to assess the diagnostic accuracy. Results Taking 2-dimensional echocardiography as the gold-standard technique, electrocardiography correctly diagnosed 68 patients as positive for left atrial enlargement and 12 as negative. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of electrocardiography for left atrial enlargement were 54.4%, 57.1%, 88.3%, 17.4%, and 54.8%, respectively. Conclusion The electrocardiogram appears to be a reasonable indicator of left atrial enlargement. In case of nonavailability of echocardiography, electrocardiography can be used for diagnosis of left atrial enlargement.

Multivessel Disease As A Prognostic Marker In Patients Presenting For Primary Percutaneous Coronary Intervention.

BACKGROUND: Multi-vessel disease is associated with higher mortality rates in ST-Elevation Myocardial Infarction (STEMI) patients, which may further alter clinical course and decision making. Hence, the purpose of this study is to determine prevalence, in hospital and early after discharge (up to 30 days) outcome of patients with multi-vessel disease as compared to single vessel disease presenting with acute STEMI undergoing Primary PCI. METHODS: This study includes 282 consecutive selected patients, presented in emergency department with acute STEMI; undergo primary percutaneous coronary intervention (PCI) at Catheterization Laboratory of National Institute of Cardiovascular Diseases (NICVD), Karachi Pakistan during the study period of 17th December 2016 to 16th June 2017. Demographic characteristics, clinical history, post procedural complications, and short term adverse clinical events in patients with SVD and MVD were assessed and compared using z-test, t-test, and Fisher's Exact test.. RESULTS: Comparing the patients with single vessel disease, multi-vessel disease patients have worse post procedural outcomes, increased overall complications, length of hospital stay, higher referral for CABG, and in-hospital mortality. On follow up relatively higher, but not statistically significant, patient with MVD developed recurrence of symptoms and got re-admission. CONCLUSIONS: Multi-vessel disease in patients presenting for primary PCI is the direct indicative of significantly higher post procedure complications, mortality, morbidity, and prolonged hospitalization. Also, risk of recurrence of symptoms and re-admission remains high in patients with multi-vessel disease..