Angiographic characteristics of culprit lesions in infarct related artery and correlation of TIMI score with SYNTAX score to predict extent and severity of coronary artery disease in patients undergoing primary percutaneous coronary interventions.

Objective: The current study was designed to explore the relationship of TIMI and SYNTAX risk score to predict the CAD extent and severity in STEMI patients. Methods: For this cross-sectional study, 304 STEMI patients undergoing PPCI were enrolled at Department of Interventional Cardiology NICVD Karachi from September 2021 to January 2022. and the TIMI risk score was determined at enrolment. Based on these scorings, the patients were grouped as low, intermediate, and high risk, i.e., a score of ≤ 3, 4 to 7, and ≥ 8, respectively. The SYNTAX scores were utilized to assess the extent of CAD. Results: Statistically significant difference was found in symptoms to balloon time (p=0.001), history of diabetes (p=0.006), angina (p=0.011), obesity (p=0.048), STEMI type (p=0.003), Killip classes (p=0.000), Infarct-Related Artery (p=0.006), number of diseased vessels (p<0.01), LMS > 50% (p=0.000), PCI type (p<0.01), collateral circulation (p<0.01), In-hospital mortality (p<0.01), LV support (p<0.01), and post-procedural TIMI flow (p=0.013), among the three TIMI risk groups. Significant correlation was found among TIMI risk score and SYNTAX score. Conclusion: It is observed that the TIMI risk scores are highly correlated with the SYNTAX Score in predicting the CAD severity in STEMI patients.

Predilation Ballooning in High Thrombus Laden STEMIs: An Independent Predictor of Slow Flow/No-Reflow in Patients Undergoing Emergent Percutaneous Coronary Revascularization.

Background: Distal embolization due to microthrombus fragments formed during predilation ballooning is considered one of the possible mechanisms of slow flow/no-reflow (SF/NR). Therefore, this study aimed to compare the incidence of intraprocedure SF/NR during the primary percutaneous coronary intervention (PCI) in patients with high thrombus burden (≥4 grade) with and without predilation ballooning for culprit lesion preparation. Methodology. This prospective descriptive cross-sectional study included patients with a high thrombus burden (≥4 grades) who underwent primary PCI. Propensity-matched cohorts of patients with and without predilation ballooning in a 1 : 1 ratio were compared for the incidence of intraprocedure SF/NR. Results: A total of 765 patients with high thrombus burden undergoing primary PCI were included in this study. The mean age was 55.75 ± 11.54 years, and 78.6% (601) were males. Predilation ballooning was conducted in 346 (45.2%) patients. The incidence of intraprocedure SF/NR was significantly higher (41.3% vs. 27.4%; p < 0.001) in patients with predilation ballooning than in those without preballooning, respectively. The incidence of intraprocedure SF/NR also remained significantly higher for the predilation ballooning cohort with an incidence rate of 41.3% as against 30.1% (p=0.002) for the propensity-matched cohort of patients without predilation ballooning with a relative risk of 1.64 (95% CI: 1.20 to 2.24). Moreover, the in-hospital mortality rate remained higher but insignificant, among patients with and without predilation ballooning (8.1% vs. 4.9%; p=0.090). Conclusion: In conclusion, predilation ballooning can be associated with an increased risk of incidence of intraprocedure SF/NR during primary PCI in patients with high thrombus burden.

Acute hyperglycemia, a rabble-rouser or innocent bystander? A prospective analysis of clinical implications of acute hyperglycemia in STE-ACS patients.

BACKGROUND: Acute hyperglycemia is considered an independent prognosticator of both in-hospital and long-term outcomes in patients with acute coronary syndrome (ACS). This study aimed To analyze the incidence of acute hyperglycemia and its impact on the adverse in-hospital outcome in patients with STE-ACS undergoing primary percutaneous coronary intervention (PCI). METHODS: In this study, we enrolled patients presenting with STE-ACS and undergoing primary PCI at a tertiary care cardiac center. Acute hyperglycemia was defined as random plasma glucose (RBS) > 200 mg/dl at the time of presentation to the emergency room. RESULTS: Of the 4470 patients, 78.8% were males, and the mean age was 55.52 ± 11 years. In total, 39.4% (1759) were found to have acute hyperglycemia, and of these, 59% (1037) were already diagnosed with diabetes. Patients with acute hyperglycemia were observed to have a higher incidence of heart failure (8.2% vs. 5.5%; p < 0.001), contrast-induced nephropathy (10.9% vs. 7.4%; p < 0.001), and in-hospital mortality (5.7% vs. 2.5%; p < 0.001). On multivariable analysis, acute hyperglycemia was found to be an independent predictor of mortality with an adjusted odds ratio of 1.81 [1.28-2.55]. Multi-vessel disease (1.73 [1.17-2.56]), pre-procedure left ventricular end-diastolic pressure (LVEDP) (1.02 [1.0-1.03]), and Killip class III/IV (4.55 [3.09-6.71]) were found to be the additional independent predictors of in-hospital mortality. CONCLUSIONS: Acute hyperglycemia, regardless of diabetic status, is an independent predictor of in-hospital mortality among patients with STE-ACS undergoing primary PCI. Acute hyperglycemia, along with other significant predictors such as multi-vessel involvement, LVEDP, and Killip class III/IV, can be considered for the risk stratification of these patients.

Depression and Anxiety in patients undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome.

BACKGROUND AND OBJECTIVE: Depression and anxiety are very common in patients with cardiac diseases. Percutaneous coronary intervention (PCI) has not only decreased mortality but angina, heart failure and recurrent hospitalization all are improved. Therefore, anxiety and depression associated with fibrinolytic therapy in acute coronary syndrome (ACS) are expected to be decreased in the patient undergoing PCI. Therefore, the aim of this study was to determine prevalence of depression and anxiety in patients undergoing percutaneous coronary intervention for acute coronary syndrome. METHODS: This study was conducted at Larkana Satellite Center of National Institute of Cardiovascular Diseases (NICVD), Pakistan from August 2018 to December 2018. Patients who underwent cardiac intervention within one month were enrolled in this study. Patients were interviewed regarding their basic demographics, indication for intervention and procedure details. Symptoms of anxiety were assessed using the translation of inventory of SAS (Zung's Self-Rating Anxiety Scale). Patients were interviewed for depression by using Becks depression inventory (BDI). RESULTS: A total of 153 patients were included in this study out of which 118 (77.1%) were males and 35 (22.5%) were females. All were married except one. Diabetes mellitus (DM) was present in 61 (39.9%), hypertension (HTN) in 69 (45.15%), obesity in 15 (9.8%), and 40 (26.1%) were smokers. Depression was present in 16 (10.5%) patients and anxiety was present in 12 (7.5%) of patients. On analysis of the association of various factor with depression; non-diabetics, housewives, laborers and uneducated were found to be more depressed. While those who smoke or earn more than 50 thousand were found less likely to be depressed. CONCLUSION: Both depression and anxiety were present in only 10.5% and 7.5% of the patients after percutaneous coronary intervention for acute coronary syndrome.

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.

Procedural determinants of fluoroscopy time in patients undergoing cardiac catheterization.

BACKGROUND & OBJECTIVE: Due to increase in number of cardiac catheterization procedures safety concerns is an issue nowadays. Multiple diagnostic modalities use radiations, which also put a patient at higher cumulative radiation exposure. Therefore steps should be taken to minimize radiation exposure during cardiac catheterization. Hence determination of factors which prolong FT will result in better understanding of problem. This retrospective study was undertaken to determine factors responsible for prolong fluoroscopy time in patients undergoing coronary artery catheterization. METHODS: This retrospective study was conducted at catheterization Laboratory National Institute of Cardiovascular Diseases, Karachi from June 2014 to June 2015. Patients of either gender, aged between 18 to 90 years undergoing cardiac catheterization procedures were included. Radiation exposure time was measured in terms of fluoroscopy time. RESULTS: A total of 957 patients were included in this study out of which 731 were of diagnostic Coronary Angiograms (CA) and 226 were of Percutaneous Coronary Intervention (PCI). The mean age of the study participants was 54.12±10.89 years and majority 734(76.6%) were male. Mean fluoroscopy time (FT) in the patients subjected to PCI was 9.61±6.07 minutes while in cases for CA 4.17±4.13 minutes. FT for CA was observed significantly dependent on procedural access, operator's experience, and LV angiogram. While FT for PCI was found dependent on number of stents deployed during the procedure. CONCLUSION: For invasive coronary angiographic procedures radial route increased fluoroscopy time. For percutaneous coronary intervention femoral and radial route fluoroscopy time were not significantly different.

Managed successfully: Iatrogenic aortic dissection during primary percutaneous coronary intervention.

Iatrogenic aortic dissection caused by primary percutaneous coronary intervention (PCI) is a rare but potentially fatal complication; therefore prompt recognition of this life-threatening condition is crucial. We present herein a case of a 70-year-old lady who underwent primary PCI for transmural myocardial infarction of left anterior descending artery territory. Manipulation of the extra backup (EBU) guiding catheter during an attempt to cannulate the left system resulted in an aortic dissection. The patient was managed conservatively with strict monitoring in the coronary care unit (CCU), and underwent serial evaluation with non-invasive imaging studies including a computed tomography angiography (CTA). On the 3rd post-procedure day, she developed cerebrovascular accident from which she recovered completely. Repeat CT angiogram showed complete resolution of the ascending aortic dissection. Initial follow-up was conducted at 2 weeks and the patient was doing well.

Safety of primary percutaneous coronary intervention with and without (selective) thrombus aspiration.

OBJECTIVE: To determine the safety and efficacy of selective thrombus aspiration during Primary Percutaneous Coronary Intervention (PCI). METHODS: This observational prospective study was conducted in the catheterization laboratory of a tertiary care cardiovascular centre. A total of 150 consecutive patients who underwent primary PCI were enrolled. Aspiration was done only when thrombus burden was considered significant. After completion of procedure angiographic and electrocardiographic signs were recorded and clinical follow up was documented up to 1 year. RESULTS: No significant difference among the groups was found in age, height, weight and other risk factors like Hypertension, Diabetes Mellitus and Smoking. In general, left anterior descending artery was culprit in - 65% of patients and more than 90% of culprit vessels had visible thrombus. Multivessel disease was present in 38% of patients and 22.7% had past history of myocardial infarction. Out of 150 patients 117 (78%) underwent thrombus aspiration. No significant difference was found in ST resolution within 60 minutes (72.6 vs 81.8%; P < 0.285) and myocardial blush grade II & III (41.9 vs 27.3%; P < 0.128). No difference in event free survival was observed among the two groups (80.3 vs 84.8%; P < 0.708) at one year. CONCLUSION: Selective thrombus aspiration in definite thrombus laden arteries and no aspiration in low or negligible thrombus burden vessels may be a safe and effective strategy in patients undergoing primary PCI. Overall poor risk profile of our patients as compared to western population necessitates further evaluation of this matter in randomized studies.

Lack of awareness of secondary rheumatic prevention in preoperative candidates for mitral valve surgery - alarming situation.

BACKGROUND: We conducted this study to assess the compliance with secondary rheumatic prophylaxis among preoperative patients with rheumatic mitral valve disease undergoing valvular heart surgery at a tertiary care cardiac hospital in a developing country. METHODS: This is a descriptive cross-sectional study conducted at a tertiary care cardiac hospital in Karachi, Pakistan. The inclusion criteria encompassed patients of any sex, aged between 18 and 80 years, who had been diagnosed with rheumatic mitral valve disease through transthoracic echocardiography and had undergone valvular heart surgery. The level of compliance with secondary rheumatic prophylaxis and barriers toward noncompliance was assessed during routine preoperative interview session. This preventive measure plays a crucial role in reducing the progression of the disease and improving patient outcomes. RESULTS: Out of the 239 patients included in the study, 125 (52.3%) were females, with a mean age of 38.8 ± 11.8 years. The majority of patients (88.7%) came from rural areas. Among the patients, 79 (33.1%) received rheumatic prophylaxis, while 160 (66.9%) did not adhere to it regularly. The common barriers for receiving rheumatic prophylaxis were non availability (41.0%) and nonaffordability (40.6%). Additionally, 28.0% of patients had lacked awareness of the importance of rheumatic prophylaxis, and 2.5% expressed fear of injection site pain and subsequent symptoms. CONCLUSIONS: A concerning level of noncompliance with secondary rheumatic prophylaxis was observed. The barriers identified in patients who did not receive rheumatic prophylaxis were primarily related to affordability, availability, lack of awareness, and fear of injection site pain and subsequent symptoms.

Age and gender-based categorization of very premature, premature, and non-premature acute myocardial infarction: A comparison of clinical and angiographic profile and in-hospital outcomes.

BACKGROUND: In this study, we aimed to assess and compare the distribution of demographic and clinical characteristics and composite adverse clinical outcomes after primary percutaneous coronary intervention (PCI) among "very premature", "premature", and "non-premature" patients with "ST-segment elevation acute coronary syndrome (STE-ACS)" presented at a tertiary care center. METHODS: We included consecutive patients diagnosed with STE-ACS undergoing primary PCI. The "very premature" was defined as ≤40 years for males and ≤ 45 years for females, "premature" as <55 years for males and < 65 years for females, and "non-premature" as ≥55 years for males and ≥ 65 years for females. Clinical characteristics, angiographic patterns, and hospital course were compared among the three groups. RESULTS: In a sample of 4686 patients, 78.8%(3691) were male, and the average age was 55.6 ± 11 years. In total, 12%(561) were categorized as very premature, 38.3%(1797) as premature, and 49.7%(2328) as non-premature. The distribution of clinical characteristics in very premature, premature, and non-premature groups were as follows; hypertension in 44.6% vs. 53.5% vs. 54.9%; p < 0.001, diabetes in 30.3% vs. 36.8% vs. 35.5%; p = 0.018, smoking in 29.6% vs. 23.3% vs. 26.3%; p = 0.005, obesity in 19.4% vs. 18.4% vs. 15.3%; p = 0.008, single vessel diseases in 58.8% vs. 37.8% vs. 28.8%; p < 0.001, and composite adverse clinical outcomes in 14.1% vs. 16.7% vs. 21.8%; p < 0.001, respectively. CONCLUSION: In conclusion, we have a substantial burden of premature STE-ACS. Very premature STE-ACS was found to be associated with a better prognosis, but a substantial burden of composite adverse clinical outcomes was also observed.

Increasing Incidence of ST-Elevation Acute Coronary Syndrome in Young South Asian Population, a Challenge for the World? An Assessment of Clinical and Angiographic Patterns and Hospital Course of Premature Acute Myocardial Infarction.

The incidence of premature ischemic heart disease (IHD) is increasing because of urbanization, a sedentary lifestyle, and various other unexplored factors, especially in South Asia. This study aimed to assess the distribution of premature ST-elevation acute coronary syndrome (STE-ACS) with its clinical and angiographic pattern along with hospital course in a contemporary cohort of patients who underwent primary percutaneous intervention at a tertiary care center in the South Asian region. We included consecutive patients of either gender diagnosed with STE-ACS and who underwent primary percutaneous intervention. Patients were stratified based on age as ≤40 years (young) and >40 years (old). Clinical characteristics, angiographic patterns, and hospital course were compared between the 2 groups. Of the total of 4,686 patients, 466 (9.9%) were young (≤40 years). Young patients had a lower prevalence of hypertension (40.8% vs 54.5%, p <0.001), diabetes (26.6% vs 36.4%, p <0.001), metabolic syndrome (14.8% vs 24%, p <0.001), history of IHD (5.8% vs 9.3%, p = 0.013) and a higher frequency of smoking (33% vs 24.7%, p <0.001), positive family history (8.2% vs 3.2%, p <0.001), and single-vessel involvement (60.1% vs 33.2%, p <0.001). The composite adverse clinical outcome occurrence was significantly lower in young patients (14.2% vs 19.5%, p = 0.006). On multivariable analysis, history of IHD in young, whereas age, Killip class III/IV, intubated, arrhythmias on arrival, diabetes, history of IHD, pre-procedure left ventricular end-diastolic pressure, ejection fraction <40%, and slow flow/no-reflow during the procedure were found to be the independent predictors of adverse clinical outcome in old patients. In conclusion, we have a substantial burden of premature STE-ACS, mostly in male patients potentially driven by smoking and positive family history. Despite favorable pathophysiology, with mostly single-vessel hospital courses of STE-ACS in the young equally lethal in nature.

Techniques to Treat Slow-Flow/No-Reflow During Primary Percutaneous Coronary Intervention.

OBJECTIVE: The aim of this study was to compare TIMI flow after administering intracoronary (IC) medications through various routes for the treatment of slow flow/no-reflow during primary PCI. METHODS: Two independent parallel cohorts of the patients who underwent primary PCI for STEMI and developed slow/no-reflow were recruited. Selection of cohort was based on the route of administration of IC medications as proximal or distal. Post administration TIMI follow was compared between the two cohorts. RESULTS: A total of 100 patients were included in both, proximal and distal, cohort. Distribution of angiographic, clinical and demographic characteristics was not significant between the two cohorts except prevalence of hypertension, and diabetes mellitus. Frequency of hypertension, and diabetes mellitus were 45 % vs.70 %; p < 0.001 and 28 % vs. 44 %; p = 0.018 among patients in distal and proximal cohort respectively. Final TIMI III flow was achieved in significantly higher number of patients in distal cohort with the frequency of 88 % vs. 76 %; p = 0.027 as compared to proximal cohort. CONCLUSION: Administration of IC medication via distal route is observed to be more effective for the treatment of slow flow/no-reflow during primary PCI. Distal route via export catheter or perforated balloon technique should be preferred wherever feasible.

One-year major adverse cardiovascular events among same-day discharged patients after primary percutaneous coronary intervention at a tertiary care cardiac centre in Karachi, Pakistan: a prospective observational study.

OBJECTIVE: Knowledge regarding the short-term outcomes after same-day discharge (SDD) post primary percutaneous coronary intervention (PCI) is lacking. In this study, we evaluated 1-year major adverse cardiovascular events (MACE) among SDD patients after primary PCI. DESIGN: 1-year follow-up analysis of a subset of patients from an existing prospective cohort study. SETTING: Tertiary care cardiac hospital in Karachi, Pakistan. PARTICIPANTS: Consecutive patients, from August 2019 to July 2020, with ST segment elevation myocardial infarction who had undergone primary PCI with SDD (within 24 hours) after the procedure by the treating physician and with at least one successful follow-up up to 1 year. OUTCOME MEASURE: Cumulative MACE during follow-up at the intervals of 1 week, 1 month, 6 months and 1 year. RESULTS: 489 patients were included, with a gender distribution of 83.2% (407) male patients and a mean age of 54.58±10.85 years. Overall MACE rate during the mean follow-up duration of 326.98±76.71 days was 10.8% (53), out of which 26.4% (14/53) events occurred within 6 months of discharge and the remaining 73.6% (39/53) occurred between 6 months and 1 year. MACE was significantly higher among patients with a Zwolle Risk Score (ZRS) ≥4 at baseline, with an incidence rate of 21.9% (16/73) vs 8.9% (37/416; p=0.001) in patients with ZRS≤3 (relative risk 2.88 (95% CI 1.5 to 5.5)). CONCLUSION: A significant burden of short-term MACE was identified among SDD patients after primary PCI; most of these events occurred after 6 months of SDD, mainly among patients with ZRS≥4. A systematic risk assessment based on risk stratification modalities such ZRS could be a viable option for SDD patients with primary PCI.

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.

Unfolding the reality of the smoking paradox in a South Asian cohort of patients presenting with ST-elevation acute coronary syndrome undergoing primary percutaneous coronary intervention.

Objectives: Smoking is a potent risk factor for coronary artery disease, but there is controversy about its protective nature in terms of prognosis in ST-elevation acute coronary syndrome patients undergoing primary percutaneous coronary intervention. So, the main objective of this study is to unfold this controversy in a South Asian population in terms of clinical angiographic parameters and its in-hospital outcomes. Methods: In this study, we included 1756 consecutive patients diagnosed with ST-elevation acute coronary syndrome undergoing primary percutaneous coronary intervention. Patients were classified into smokers and non-smokers, and the in-hospital mortality rate was compared. Multivariable logistic regression analysis was performed to evaluate the paradoxical role of smoking. Results: Smokers were younger (53.78 ± 11.16 years vs 56.43 ± 11.17 years; p < 0.001) and more frequently men (98.7% vs 69.9%; p < 0.001) and had less diabetes (19.6% vs 44.8%; p < 0.001) and hypertension (38.5% vs 64.9%; p < 0.001). Smokers presented less frequently in Killip III (5.6% vs 8.1%; p < 0.001) and Killip IV (2.5% vs 4.8%; p < 0.001). Smokers mostly had single vessel disease (41.7% vs 34.4%; p = 0.013), whereas non-smokers had the multi-vessel disease and frequently presented with total occlusion of the culprit vessel (64.6% vs 58.8%; p = 0.040). Smokers have significantly lesser mortality (1.8% vs 4.3%; p = 0.009) compared to non-smokers with an odds ratio of 0.41 (95% confidence interval (CI): 0.21-0.82, p = 0.011); however, adjusted odds ratio on multivariable analysis was 0.67 (95% CI: 0.31-1.41, p = 0.290). Conclusions: The paradoxical protective role of smoking is the confounding effect of mainly younger age, less coronary artery disease burden, lower prevalence of diabetes and hypertension, and lower Killip III/IV at presentation.

Quantification Of Thrombus Burden As An Independent Predictor Of Intra-Procedural No-Reflow In Patients With St-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Revascularization.

BACKGROUND: Aim of this study was to perform quantitative evaluation of high thrombus burden (Grade ≥4) as an independent predictor of slow/no reflow phenomenon during primary percutaneous coronary interventions (PCI) of patients with ST-segment elevation myocardial infarction (STEMI). METHODS: In this analytical cross-sectional study we included consecutive patients who have undergone primary PCI for STEMI at a tertiary care cardiac center of the Pakistan. High thrombus burden was defined as angiographic thrombus grade ≥4. The thrombolysis in myocardial infarction (TIMI) flow rate < III was defined as slow/no reflow phenomenon. Results of multivariate logistic regression analysis for slow/no reflow phenomenon were reported as odds ratio (OR). RESULTS: This analysis included 747 patients, 78.2% (584) patients were male and mean age was 55.82±11.54 years. High thrombus burden was observed in 68.1% (509) of the patients. Slow/no reflow phenomenon was observed in 33.6% (251) which was more common among patients in high thrombus burden group, 39.7% (202/509) vs. 20.6% (49/238); p<0.001. Adjusted OR of thrombus Grade ≥ 4 was 2.33 [1.6 -3.39]; p<0.001. Other significant variables were female gender (1.51 [1.01 -2.27]; p=0.045), left ventricular end-diastolic pressure (LVEDP) ≥20 mmHg (2.34 [1.69 -3.26]; p<0.001), total lesion length ≥20 cm (1.54 [1.09-2.16]; p=0.014), and neutrophil count ≥8.8 cells/µL (1.72 [1.22 -2.43]; p=0.002). CONCLUSIONS: High thrombus burden (Grade ≥4) is a significant and an independent predictor of the slow/no reflow phenomenon. While predicting slow/no reflow phenomenon, thrombus burden should be given due importance along with other significant factors such as gender, LVEDP, lesion length, and neutrophil counts.

Comparison of Intracoronary Epinephrine and Adenosine for No-Reflow in Normotensive Patients With Acute Coronary Syndrome (COAR Trial).

BACKGROUND: Intracoronary epinephrine has been effectively used in treating refractory no-reflow, but there is a dearth of data on its use as a first-line drug in normotensive patients in comparison to the widely used adenosine. METHODS: In this open-labeled randomized clinical trial, 201 patients with no-reflow were randomized 1:1 into intracoronary epinephrine as the treatment group and intracoronary adenosine as the control group and followed for 1 month. The primary end points were improvement in coronary flow, as assessed by TIMI (Thrombolysis in Myocardial Infarction) flow, frame counts, and myocardial blush. Secondary end points were in-hospital and short-term mortality and major adverse cardiac events. RESULTS: In all, 101 patients received intracoronary epinephrine and 100 patients received adenosine. Epinephrine was generally well tolerated with no immediate table death or ventricular fibrillation. No-reflow was more effectively improved with epinephrine with final TIMI III flow (90.1% versus 78%, P=0.019) and final corrected TIMI frame count (24±8.43 versus 26.63±9.22, P=0.036). However, no significant difference was observed in final grade III myocardial blush (55.4% versus 45%, P=0.139), mean reduction of corrected TIMI frame count (-25.71±11.79 versus -26.08±11.71, P=0.825), in-hospital and short-term mortality, and major adverse cardiac events. CONCLUSIONS: Epinephrine is relatively safe to use in no-reflow in normotensive patients. A significantly higher frequency of post-treatment TIMI III flow grade and lower final corrected TIMI frame count with relatively better achievement of myocardial blush grade III translate into it displaying relatively better efficacy than adenosine. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04699110.

Comparative analysis of four established risk scores for prediction of in-hospital mortality in patients undergoing primary percutaneous coronary intervention.

OBJECTIVE: This study was conducted to compare the predictive power of Shock Index (SI), TIMI Risk Index (TRI), LASH Score, and ACEF Score for the prediction of in-hospital mortality in a contemporary cohort of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center of a developing country. METHODS: Consecutive patients diagnosed with STEMI and undergoing primary PCI were included in this study. SI, TRI, LASH, and ACEF were computed and their predictive power was assessed as the area under the curve (AUC) on the receiver operating characteristics (ROC) curve analysis for in-hospital mortality. RESULTS: We included 977 patients, 780 (79.8%) of which were male, and the mean age was 55.6 ± 11.5 years. The in-hospital mortality rate was 4.3% (42). AUC for TRI was 0.669 (optimal cutoff: ≥17.5, sensitivity: 76.2%, specificity: 45.6%). AUC for SI was 0.595 (optimal cutoff: ≥0.9, sensitivity: 21.4%, specificity: 89.8%). AUC for LASH score was 0.745 (optimal cutoff: ≥0, sensitivity: 76.2%, specificity: 66.9%). AUC for the ACEF score was 0.786 (optimal cutoff: ≥1.66, sensitivity: 71.4%, specificity: 73.5%). CONCLUSION: In conclusion, ACEF showed sufficiently high predictive power with good sensitivity and specificity compared to other three scores. These simplified indices based on readily available hemodynamic parameters can be reliable alternatives to the computational complex scoring systems for the risk stratification of STEMI patients.

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.

Incidence, Predictors, and Outcomes of Acute and Sub-acute Stent Thrombosis after Emergency Percutaneous Coronary Revascularization with Drug-Eluting Stents: A Prospective Observational Study.

Background: Stent thrombosis (ST) remains the most feared complication of percutaneous coronary intervention (PCI). Therefore, this study aimed to determine acute and sub-acute ST incidence, predictors, and outcomes after primary PCI. Methods: This prospective observational study included patients who had undergone primary PCI at a tertiary care cardiac center. All the patients were followed at 30-days of index hospitalization for the incidence of acute or sub-acute ST. ST was further categorized as definite, probable, or possible per the Academic Research Consortium definition. All the survivors of ST were followed after 6-months for the incidence of major adverse cardiovascular events. Results: An aggregate of 1756 patients were included with 79% (1388) male patients and mean age was 55.59 ± 11.23 years. The incidence of ST was 4.9% (86) with 1.3% (22) acute and 3.6% (64) sub-acute. ST was categorized as definite in 3.3% (58) and probable in 1.6% (28). Independent predictor of ST were observed to be male gender (odds ratio (OR); 2.51 [1.21-5.2]), left ventricular end-diastolic pressure ≥20 mmHg (OR; 2.55 [1.31-4.98]), and pre-procedure thrombolysis in myocardial infarction (TIMI) flow 0 (OR; 3.27 [1.61-6.65]). Cumulative all-cause mortality among patients with ST after 164.1 ± 76.2 days was 46.5% (40/86). Conclusion: We observed a substantial number of patients vulnerable to the acute or sub-acute ST after primary PCI. Male gender, LVEDP, pre-procedure TIMI flow grade can be used to identify and efficiently manage highly vulnerable patients.