A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction.

BACKGROUND: Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice. METHODS: We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort. RESULTS: In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P < .001 vs best emergency medicine doctor). CONCLUSIONS: Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

Relationship between coronary volume, myocardial mass, and post-PCI fractional flow reserve.

BACKGROUND: Fractional flow reserve (FFR) measured after percutaneous coronary intervention (PCI) carries prognostic information. Yet, myocardial mass subtended by a stenosis influences FFR. We hypothesized that a smaller coronary lumen volume and a large myocardial mass might be associated with lower post-PCI FFR. AIM: We sought to assess the relationship between vessel volume, myocardial mass, and post-PCI FFR. METHODS: This was a subanalysis with an international prospective study of patients with significant lesions (FFR ≤ 0.80) undergoing PCI. Territory-specific myocardial mass was calculated from coronary computed tomography angiography (CCTA) using the Voronoi's algorithm. Vessel volume was extracted from quantitative CCTA analysis. Resting full-cycle ratio (RFR) and FFR were measured before and after PCI. We assessed the association between coronary lumen volume (V) and its related myocardial mass (M), and the percent of total myocardial mass (%M) with post-PCI FFR. RESULTS: We studied 120 patients (123 vessels: 94 left anterior descending arteries, 13 left Circumflex arteries, 16 right coronary arteries). Mean vessel-specific mass was 61 ± 23.1 g (%M 39.6 ± 11.7%). The mean post-PCI FFR was 0.88 ± 0.06 FFR units. Post-PCI FFR values were lower in vessels subtending higher mass (0.87 ± 0.05 vs. 0.89 ± 0.07, p = 0.047), and with lower V/M ratio (0.87 ± 0.06 vs. 0.89 ± 0.07, p = 0.02). V/M ratio correlated significantly with post-PCI RFR and FFR (RFR r = 0.37, 95% CI: 0.21-0.52, p < 0.001 and FFR r = 0.41, 95% CI: 0.26-0.55, p < 0.001). CONCLUSION: Post-PCI RFR and FFR are associated with the subtended myocardial mass and the coronary volume to mass ratio. Vessels with higher mass and lower V/M ratio have lower post-PCI RFR and FFR.

Elevated Native T1 Values in the Remote Myocardium Supplied by Obstructive Non-Infarct Related Coronary Arteries in Post-STEMI Cardiac Magnetic Resonance.

INTRODUCTION: Native T1 mapping values are elevated in acutely injured myocardium. We sought to study whether native T1 values, in the non-infarct related myocardial territories, might differ when supplied by obstructive or nonobstructive coronary arteries. METHODS: Consecutive patients (N = 60, mean age 59 years) with the first STEMI following primary percutaneous coronary intervention, underwent cardiac magnetic resonance within 5 ± 2 days. A retrospective review of coronary angiography reports classified coronary arteries as infarct-related coronary artery (IRA) and non-IRA. Obstructive coronary artery disease (CAD) was defined as stenosis ≥50%. Native T1 values were presented using a 16-segment AHA model according to the three main coronary territories: left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). RESULTS: The cutoff native T1 value for predicting obstructive non-IRA LAD was 1,309 msec with a sensitivity and specificity of 67% and 82%, respectively (AUC 0.76, 95% CI: 0.57-0.95, p = 0.04). The cutoff native T1 value for predicting obstructive non-IRA RCA was 1,302 msec with a sensitivity and specificity of 83% and 55%, respectively (AUC 0.7, 95% CI: 0.52-0.87, p = 0.05). Logistic regression model adjusted for age and infarct size demonstrated that native T1 was an independent predictor for the obstructive non-IRA LAD (OR 4.65; 1.32-26.96, p = 0.05) and RCA (OR 3.70; 1.44-16.35, p = 0.03). CONCLUSION: Elevated native T1 values are independent predictors of obstructive non-IRA in STEMI patients. These results suggest the presence of concomitant remote myocardial impairment in the non-infarct territories with obstructive CAD.

Intracoronary Thrombolysis in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: an Updated Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Primary percutaneous coronary intervention (PPCI) is the standard reperfusion treatment in ST-segment elevation myocardial infarction (STEMI). Intracoronary thrombolysis (ICT) may reduce thrombotic burden in the infarct-related artery, which is often responsible for microvascular obstruction and no-reflow. METHODS: We conducted, according to the PRISMA statement, the largest meta-analysis to date of ICT as adjuvant therapy to PPCI. All relevant studies were identified by searching the PubMed, Scopus, Cochrane Library, and Web of Science. RESULTS: Thirteen randomized controlled trials (RCTs) involving a total of 1876 patients were included. Compared to the control group, STEMI ICT-treated patients had fewer major adverse cardiac events (MACE) (OR 0.65, 95% CI, 0.48-0.86, P = 0.003) and an improved 6-month left ventricular ejection fraction (MD 3.78, 95% CI, 1.53-6.02, P = 0.0010). Indices of enhanced myocardial microcirculation were better with ICT (Post-PCI corrected thrombolysis in myocardial infarction (TIMI) frame count (MD - 3.57; 95% CI, - 5.00 to - 2.14, P < 0.00001); myocardial blush grade (MBG) 2/3 (OR 1.76; 95% CI, 1.16-2.69, P = 0.008), and complete ST-segment resolution (OR 1.97; 95% CI, 1.33-2.91, P = 0.0007)). The odds for major bleeding were comparable between the 2 groups (OR 1.27; 95% CI, 0.61-2.63, P = 0.53). CONCLUSIONS: The present meta-analysis suggests that ICT was associated with improved MACE and myocardial microcirculation in STEMI patients undergoing PPCI, without significant increase in major bleeding. However, these findings necessitate confirmation in a contemporary large RCT.

Impact of percutaneous coronary intervention on chronic total occlusion in the non-infarct-related artery in patients with STEMI: a systematic review and meta-analysis.

OBJECTIVES: We sought to compare the clinical outcomes between culprit-only percutaneous coronary intervention (PCI) versus multivessel PCI (MV-PCI) in patients with ST-segment elevation myocardial infarction (STEMI) accompanied by chronic total occlusion (CTO) in the non-infarct-related artery(non-IRA). DESIGN: Studies that compared culprit-only PCI versus MV-PCI in patients with STEMI accompanied by CTO in the non-IRA were included. Random odds ratio (OR) and 95% confidence interval (CI) were calculated. RESULTS: Eight studies with 2,259 patients were included. The results suggested that in patients with STEMI accompanied by CTO in the non-IRA, culprit-only PCI was associated with higher risks of all-cause mortality (OR: 2.89; 95% CI: 2.09-4.00; I2 = 0.0%), cardiac death (OR: 3.12; 95% CI: 2.05-4.75; I2 = 16.8%), stroke (OR: 2.80; 95% CI: 1.04-7.53; I2 = 0.0%), major adverse cardiovascular event (MACE; OR: 2.06; 95% CI: 1.39-3.06; I2 = 54.0%), and heart failure (OR: 1.99; 95% CI: 1.22-3.24; I2 = 0.0%) compared with staged MV-PCI, which were mainly derived from retrospective studies. No differences were observed in myocardial infarction or revascularization. Pooled multivariable adjusted results consistently indicated that staged MV-PCI was superior to culprit-only PCI. CONCLUSIONS: For patients with STEMI accompanied by CTO in the non-IRA, staged MV-PCI may be better compared with culprit-only PCI due to potential reduced risks of all-cause mortality, cardiac death, stroke, MACE, and heart failure. Meanwhile, further randomized trials are warranted to confirm or refute our findings.

Cardiac and sudden death after chronic total occlusion percutaneous coronary intervention: Prognostic role of the target vessel.

BACKGROUND: The role of the target vessel in percutaneous revascularization of chronic total occlusion (CTO) is unclear. OBJECTIVE: We sought to assess the long-term results of percutaneous coronary intervention (PCI) for CTO lesions in each coronary artery and to investigate the impact of successful revascularization and previous myocardial infarction (MI) in the territory of the target vessel. METHODS AND RESULTS: Cohort observational study on 1,124 patients who have undergone CTO PCI attempt: 371 on left anterior descending artery (LAD), 485 right coronary artery, and 268 left circumflex. Patients were further stratified by successfully revascularized and not-revascularized CTO (CTO-NR). Vessels affected by a previous MI were defined as infarct-related artery (IRA). The primary endpoint was cardiac death; the secondary endpoint was the combined rate of sudden cardiac-death and sustained ventricular-arrhythmias (SCD/SVAs). Propensity score-matching was performed to evaluate LAD versus NON-LAD CTO. Up to 12-year follow-up, the clinical benefit associated with successful PCI was consistent across the three groups. CTO-NR had the greatest association with cardiac death and SCD/SVAs in each coronary artery and in IRA-CTO patients. CONCLUSIONS: Unsuccessful percutaneous CTO revascularization was associated with lower cardiac survival and freedom from SCD/SVAs, irrespective of the vessel treated. This result was mainly driven by patients with an IRA CTO.

The association between T wave inversion in leads with ST-elevation and patency of the infarct-related artery.

BACKGROUND: Up to over half of the patients with ST-segment elevation myocardial infarction (STEMI) are reported to undergo spontaneous reperfusion without therapeutic interventions. Our objective was to evaluate the applicability of T wave inversion in electrocardiography (ECG) of patients with STEMI as an indicator of early spontaneous reperfusion. METHODS: In this prospective study, patients with STEMI admitted to a tertiary referral hospital were studied over a 3-year period. ECG was obtained at the time of admission and patients underwent a PPCI. The association between early T wave inversion and patency of the infarct-related artery was investigated in both anterior and non-anterior STEMI. RESULTS: Overall, 1025 patients were included in the study. Anterior STEMI was seen in 592 patients (57.7%) and non-anterior STEMI in 433 patients (42.2%). Among those with anterior STEMI, 62 patients (10.4%) had inverted T and 530 (89.6%) had positive T waves. In patients with anterior STEMI and inverted T waves, a significantly higher TIMI flow was detected (p value = 0.001); however, this relationship was not seen in non-anterior STEMI. CONCLUSION: In on-admission ECG of patients with anterior STEMI, concomitant inverted T wave in leads with ST elevation could be a proper marker of spontaneous reperfusion of infarct related artery.

Total Occlusion of the Infarct-Related Artery in Non-ST-Elevation Myocardial Infarction (NSTEMI)-How Can We Identify These Patients?

Background and Objectives: Regardless of the improvement in key recommendations in non-ST-elevation myocardial infarction (NSTEMI), the prevalence of total occlusion (TO) of infarct-related artery (IRA), and the impact of TO of IRA on outcomes in patients with NSTEMI, remain unclear. Aim: The study aimed to assess the incidence and predictors of TO of IRA in patients with NSTEMI, and its clinical significance. Material and Methods: The study was a single-center retrospective cohort analysis of 399 consecutive patients with NSTEMI (293 male, mean age: 71 ± 10.1 years) undergoing percutaneous coronary intervention. The study population was categorized into patients with TO and non-TO of IRA on coronary angiography. In-hospital and one-year mortality were analyzed. Results: TO of IRA in the NSTEMI population occurred in 138 (34.6%) patients. Multivariate analysis identified the following independent predictors of TO of IRA: left ventricular ejection fraction (odds ratio (OR) 0.949, p < 0.001); family history of coronary artery disease (CAD) (OR 2.652, p < 0.001); and high-density lipoprotein (HDL) level (OR 0.972, p = 0.002). In-hospital and one-year mortality were significantly higher in the TO group than the non-TO group (2.8% vs. 1.1%, p = 0.007 and 18.1% vs. 6.5%, p < 0.001, respectively). The independent predictors of in-hospital mortality were: left ventricular ejection fraction (LVEF) at admission (OR 0.768, p = 0.004); and TO of IRA (OR 1.863, p = 0.005). Conclusions: In the population of patients with NSTEMI, TO of IRA represents a considerably frequent phenomenon, and corresponds with impaired outcomes. Therefore, the utmost caution should be paid to prevent delay of coronary angiography in NSTEMI patients with impaired left ventricular systolic function, metabolic disturbances, and a family history of CAD, who are at increased risk of TO of IRA.

Effects of nursing methods for emergency pci and non-emergency PCI on the treatment of patients with acute myocardial infarction.

OBJECTIVE: To study the effect of emergency nursing methods on the treatment of acute myocardial infarction (AMI). METHODS: A total of 100 patients with AMI were divided into emergency percutaneous coronary intervention (PCI) group (group A, 50 cases) and non-emergency PCI control group (group B, 50 cases). The clinical outcome, average left ventricular ejection fraction (LVEF), angina pectoris, heart failure, and reperfusion arrhythmia after myocardial infarction were compared between the two groups. RESULTS: The average hospitalization days of emergency PCI group were less than those of the control group, and the incidence of angina pectoris and heart failure after myocardial infarction was lower than that of the control group. The average LVEF of emergency PCI group was higher than that of the control group. CONCLUSIONS: This shows that emergency nursing of AMI can quickly and efficiently dredge the infarcted artery, reduce the occurrence of cardiovascular events after AMI and the average hospitalization days of patients, improve the left ventricular function and prevent heart failure. This method is a very effective treatment for improving the prognosis in patients with AMI.

Complete versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a meta-analysis of randomized trials.

BACKGROUND: The best strategy for the treatment of the non-infarct artery in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) undergoing primary percutaneous coronary intervention (PCI) is not yet defined. METHODS: We searched the literature for randomized controlled trials (RCTs) that compared complete revascularization (CR) with infarct-related coronary artery (IRA) only revascularization in hemodynamically stable patients with STEMI. Random effect risk ratios (RRs) were calculated for clinical outcomes. RESULTS: Nine RCTs with 2989 patients were included. No significant difference in all-cause mortality emerged between CR and IRA-only groups (relative risk [RR] = 0.74; 95% confidence interval [CI]: 0.52 to 1.04; p = 0.08). Compared with IRA-only, CR was associated with significantly lower rates of major adverse cardiac events (MACE) (RR = 0.53; 95% CI: 0.41 to 0.68; p < 0.001), cardiac death (RR = 0.48; 95% CI: 0.29 to 0.79; p = 0.004) and repeat revascularization (RR = 0.38; 95% CI: 0.30 to 0.47; p < 0.001). In subgroups analysis, immediate complete revascularization (ICR) reduced the risk of all-cause mortality (RR = 0.62; 95% CI: 0.39 to 0.97; p = 0.04), whereas staged complete revascularization (SCR) did not show any significant benefit in all-cause mortality (RR = 0.92; 95% CI: 0.46 to 1.86; p = 0.82). Stroke, contrast-induced nephropathy and major bleeding were not different between CR and IRA-only. CONCLUSIONS: For patients with STEMI and multivessel disease undergoing primary PCI, complete revascularization did not decrease the risk of all-cause mortality in current evidence from randomized trials. When feasible, immediate complete revascularization might be considered in patients with STEMI and multivessel disease.

The predictive value of aVR in determining the infarct related artery during primary percutaneous coronary intervention.

BACKGROUND: Isolation of infract related artery and timely revascularisation remains vital in the setting of primary percutaneous coronary intervention. OBJECTIVES: To analyse the predictive value of ST-T changes in lead aVR in inferior myocardial infarction in terms of prognosis and timely risk stratification. METHODS: We conducted a prospective analysis of acute inferior wall myocardial infarction patients. One hundred patients were categorised into two groups according to the culprit artery: group I, right coronary artery (RCA) and group II, left circumflex coronary artery (LCX), with 50 patients in each group. A comparative study was performed between the two groups, comprising the following data outputs: electrocardiogram (ECG) changes that could help determine the culprit artery, cardiac enzyme levels, echocardiographic findings, coronary angiography findings and in-hospital complications. The same patients were divided into two groups according to the presence or absence of 1 mm ST depression in lead aVR. A comparison analysis was performed between the two groups including: cardiac enzyme levels, echocardiographic findings, coronary angiography findings and in-hospital complications. RESULTS: ST depression in aVR ≥ 1 mm predicted the LCX as a culprit artery with sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) recorded at 66%, 84%, 80.5% and 71.2%, respectively. Also, patients with ST depression in aVR ≥ 1 mm showed significantly higher cardiac enzyme levels, indicating larger infarct size, with mean peak creatinine kinase (CK) = 1560 (1057-2375) IU/L versus 970 (613-1683) IU/L, (P value = 0.014), lower ejection fraction (Ef) with mean Ef = 47.93 ±â€¯8.04 versus 54.66 ±â€¯6.52, (P value < 0.001) and more significant mitral regurgitation: 17 (41.5%) patients versus 11 (18.6%) patients (P value = 0.012). Regarding in-hospital complications, there were no significant differences. CONCLUSIONS: ST depression of >1 mm in lead aVR predicts LCX as the infarct related artery and is a predictor of poor outcome in patients with inferior myocardial infarction.

Association of Serum Copeptin Levels with Patency of Infarct-Related Arteries in Patients with ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Copeptin is widely used as a predictor of an adverse prognosis in many clinical conditions. Reduced antegrade coronary flow in an infarct-related artery (IRA) is associated with adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate whether copeptin level on admission was associated with IRA patency in STEMI patients. METHODS: A total of 88 patients were enrolled into the study and divided into two groups according to TIMI flow grade in the IRA before primary percutaneous coronary intervention. RESULTS: White blood cell count (p = 0.015), neutrophils (p = 0.047), N-terminal pro-brain natriuretic peptide (NTproBNP) (p < 0.001), copeptin (p < 0.001) and peak troponin I (p = 0.001) were significantly higher in the occluded IRA group with a significantly lower serum sodium level (p < 0.001). Age- and gender-adjusted multivariate analysis revealed that copeptin (OR = 1.970; p = 0.001), peak troponin I (1.055; p = 0.005) and NTproBNP (OR = 1.003; p = 0.010) were independent predictors of an occluded IRA. A copeptin cut-off value of > 6.8 ng/mL was found to predict an occluded IRA with a sensitivity of 80% and specificity of 100% (area under the curve: 0.917; p < 0.001). Performance ranking of the biomarkers that could predict an occluded IRA showed copeptin > peak troponin I = NTproBNP. CONCLUSIONS: Copeptin levels were higher in the patients with an occluded IRA and STEMI. Higher levels of copeptin predicted an occluded IRA in the patients with STEMI who were admitted to the emergency department during the first three hours of chest pain.

Pre-Procedural Thrombolysis in Myocardial Infarction Flow in Patients with ST-Segment Elevation Myocardial Infarction.

It has been shown that the patency of an infarct-related artery (IRA) before primary percutaneous coronary intervention determines post-procedural success, better preservation of left ventricular function, and lower in-hospital mortality. However, the factors associated with pre-procedural Thrombolysis In Myocardial Infarction (TIMI) flow have not been fully investigated.The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted at 28 Japanese medical institutions between July 2012 and March 2014. We enrolled 3,283 consecutive patients with acute myocardial infarction who were admitted to a participating institution within 48 hours of symptom onset. There were 2,262 patients (68.9%) with ST-elevation myocardial infarction (STEMI), among whom 2,182 patients underwent emergent or urgent coronary angiography.Pre-procedural TIMI flow grade 3 was related to post-procedural TIMI flow grade 3 (P < 0.001), lower enzymatic infarct size (P < 0.001), lower ventricular tachycardia and ventricular fibrillation (P = 0.049), and lower in-hospital mortality (P = 0.020). A history of antiplatelet drug use was associated with pre-procedural TIMI flow.Antiplatelet drug use on admission was associated with pre-procedural TIMI flow. The patency of the IRA in patients with STEMI was related to procedural success and decreased enzymatic infarct size, fatal arrhythmic events, and in-hospital mortality.

Outcome of poor initial TIMI flow in patients presenting with acute coronary syndrome.

OBJECTIVES: We explored the predictors and outcome of poor, versus good, initial TIMI flow in patients with acute coronary syndrome (ACS). DESIGN: We performed post-hoc analysis of a randomized trial of patients presenting with ACS who received 2 comparative stents. Poor initial TIMI flow was defined as baseline TIMI flow grade 0/1 at the initial coronary angiography. The primary endpoint was major adverse cardiac events (MACE): a composite of cardiac death, non-fatal myocardial infarction or ischemia-driven target lesion revascularization. Stent thrombosis (ST) was adjudicated according to the criteria of definite ST described by the Academic Research Consortium. Propensity score-matched analysis was performed. We report data after 5-year follow-up. RESULTS: Of 827 patients enrolled, 279 (33.7%) had initial TIMI 0/1 flow. Median follow-up duration was 5.0 years. Presentation by ST-elevation myocardial infarction and target vessel other than left anterior descending artery predicted initial TIMI 0/1 flow. MACE rate was comparable between the 2 subgroups (14% versus 15.9%, in patients with poor versus good initial TIMI flow, respectively, p = .46). Individual endpoints were comparable (p > .05 for all). Definite ST was more frequent in patients with initial TIMI 0/1 flow (3.6% versus 1.5%, respectively, p = .048). This was driven by more frequent early events (30 days) (p = .036); late/very late events were comparable (p = 1.0). CONCLUSIONS: Predictors of poor initial TIMI flow included presentation by ST-elevation myocardial infarction, and target vessel other than left anterior descending artery. Definite ST occurred more in patients with poor, versus good, initial TIMI flow, mainly driven by difference in early events.

Outcomes After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Caused by Ectatic Infarct Related Arteries.

BACKGROUND: There is minimal published data on outcomes of patients presenting with ST elevation myocardial infarction (STEMI) due to an ectatic infarct-related artery (EIRA). The aim of this study was to analyse the clinical characteristics and outcomes of these patients presenting for primary percutaneous coronary intervention (P-PCI) in comparison with non-EIRA. METHODS: Of the 1834 patients who presented at our institution for P-PCI between February 2008 and November 2013, 25 (1.4%) were identified as having an EIRA. These patients were compared with those with non-EIRA (80 patients) who were age, gender and lesion matched. Further sub-group analysis on in-hospital and long-term outcomes was done comparing EIRA stented and non-stented patients. Clinical events evaluated include death, recurrent infarction, unstable angina, or target lesion revascularisation (TLR). RESULTS: Baseline characteristics were similar between patients with EIRA and non-EIRA although none of those with EIRA had diabetes mellitus. By comparison to the non-EIRA group, the major procedural differences for patients with EIRA were (1) a greater incidence of large thrombus burden (96.0% vs 22.5%, p=0.0001), (2) increased usage of peri-procedural glycoprotein IIb/IIIa inhibitors (72.0% vs 37.5%, p=0.01) and post-procedural anticoagulation (28.0% vs 5.0%, p=0.004), (3) larger mean stent dimension (3.9±0.8mm vs 3.4±0.6mm, p=0.04) and (4) a higher percentage of P-PCI cases that did not have stent deployment (44.0% vs 7.5%, p=0.0001). Patients with STEMI from EIRA had similar in-hospital outcomes but a higher long-term incidence of composite cardiovascular events at mean follow-up of 36.6±14.1months (44.0% vs 16.3% for non-EIRA, p=0.01). Although patients with EIRA who received stenting had better in-hospital outcomes than the non-stented cohort (composite cardiovascular event rate: 0.0% vs 36.4%, p=0.03), long-term outcomes were comparable (35.7% vs 54.6%, p=0.59) due to a relatively high frequency of non-fatal MI and unstable angina in both groups. CONCLUSION: Patients with STEMI due to EIRA carry worse long-term outcomes than those with non-EIRA. While successful stent deployment in the setting of EIRA improves procedural and inpatient success rates, it does not necessarily convey benefit to long-term event rates due to recurrent acute coronary syndromes.

Increased red cell distribution width predicts occlusion of the infarct-related artery in STEMI.

OBJECTIVE: Infarct-related artery (IRA) patency yields a better outcome in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Red cell distribution width (RDW) emerges as a marker of adverse cardiovascular events and mortality in STEMI. Therefore, we aimed to assess the relationship between IRA patency and RDW value on admission in patients with STEMI undergoing primary PCI. METHODS: A total of 564 patients with STEMI undergoing primary PCI were recruited in this study. According to thrombolysis in myocardial infarction (TIMI) flow grade in the IRA before PCI, the study population was divided into two groups as TIMI 0 or 1 group (occluded IRA, n = 398) and TIMI 2 or 3 group (patent IRA, n = 166). RESULTS: RDW was significantly higher in the occluded IRA group (15.1 ± 1.7 versus 13.4 ± 1.3, p < 0.001) as compared to the patent IRA group. White blood cell (WBC) count, platelet count, creatine kinase-myocardial band (CK-MB) and troponin-I levels were also significantly higher in the occluded IRA group (p < 0.05). Moreover, RDW showed positive correlations with troponin-I (r = 0.397, p < 0.001), CK-MB (r = 0.344, p < 0.001) and WBC (r = 0.219, p < 0.001). In multivariate regression analysis, RDW (OR: 0.483, 95% CI: 0.412-0.567, p < 0.001) and WBC count were significantly and independently associated with IRA patency. CONCLUSIONS: Our findings suggested that RDW value and WBC count on admission were independent predictors of IRA patency in patients with STEMI. As RDW is an easily available, simple and cheap biomarker, it can be used in daily practice as a novel predictor for IRA patency.

Red cell distribution width predicts totally occluded infarct-related artery in NSTEMI.

Objective Since non-ST segment elevation myocardial infarction (NSTEMI) patients with totally occluded infarct-related artery (TO-IRA) have worse prognosis, it is important to recognize TO-IRA in NSTEMI. Red cell distribution width (RDW) and mean platelet volume (MPV) are novel markers of inflammation and oxidative stress and were associated with poor clinical outcomes in acute coronary syndrome. In the present study, association of RDW and MPV with the presence of TO-IRA in NSTEMI was investigated. Methods Data of 201 consecutive patients who underwent coronary angiography with a diagnosis of NSTEMI were analyzed. Independent predictors of TO-IRA were investigated with logistic regression analysis. Results Sixty-six (32.8%) of the patients had TO-IRA. In patients with TO-IRA, RDW and troponin-T were significantly higher and left ventricular ejection fraction (LVEF) was lower. MPV did not differ between groups. Circumflex (CX) IRA was more common in TO-IRA group. The ROC curve analysis showed that the RDW at a cut-point of 13.95% has 76% sensitivity and 66% specificity in detecting TO-IRA. RDW, troponin-T, LVEF and CX-IRA were independent predictors of TO-IRA in NSTEMI, but MPV was not. Conclusion RDW is a cheap and readily available marker that may have a role to predict TO-IRA in NSTEMI.

Detection of culprit coronary lesion location in pre-hospital 12-lead ECG.

BACKGROUND: Pre-hospital 12-lead ECG interpretation is important because pre-hospital activation of the coronary catheterization laboratory reduces ST-segment elevation myocardial infarction (STEMI) discovery-to-treatment time. In addition, some ECG features indicate higher risk in STEMI such as proximal left anterior descending (LAD) culprit lesion location. The challenging nature of the pre-hospital environment can lead to noisier ECGs which make automated STEMI detection difficult. We describe an automated system to classify lesion location as proximal LAD, LAD, right coronary artery (RCA) and left circumflex (LCx) and test the performance on pre-hospital 12-lead ECG. METHODS: The overall classifier was designed from three linked classifiers to separate LAD from non-LAD (RCA or LCx) in the first step, RCA from LCx in a second classifier and proximal from non-proximal LAD in the third classifier. The proximal LAD classifier was designed for high specificity because the output may be used in the decision to modify treatment. The LCx classifier was designed for high specificity because RCA is dominant in most people. The system was trained on a set of emergency department ECGs (n=181) and tested on a set of pre-hospital ECGs (n=80). Both sets were based on a sequential sample starting with symptoms suggesting acute coronary syndromes. Culprit lesion location was determined from coronary catheterization laboratory reports. Inclusion criteria included STEMI interpretation by computer and culprit lesion with 70% or more narrowing. Algorithm accuracy was measured on the test set by sensitivity (SE), specificity (SP), and positive predictive value (PPV). RESULTS: SE, SP and PPV were 50, 100 and 100% respectively for proximal LAD lesion location; 90, 100 and 100% for all LAD; 98, 72 and 78% for RCA; and 50, 98 and 90% for LCx. Specificity and PPV were high for proximal LAD, LAD and LCx. Specificity and PPV are not as high for RCA by design since the RCA-LCx tradeoff favors high specificity in LCx. CONCLUSION: Although our test database is not large, algorithm performance suggests culprit lesion location can be reliably determined from pre-hospital ECG. Further research is needed however to evaluate the impact of automated culprit lesion location on patient treatment and outcomes.

The central role of conventional 12-lead ECG for the assessment of microvascular obstruction after percutaneous myocardial revascularization.

Guidelines report that the optimal treatment for ST-elevation myocardial infarction (STEMI) is a primary percutaneous coronary intervention (PPCI) when performed timely by trained operators. Yet, the reopening of the infarct-related artery (IRA) is not always followed by myocardial reperfusion. This phenomenon is most commonly called "no-reflow", is caused by microvascular obstruction (MVO) and is associated to a worse outcome. Electrocardiogram (ECG) is crucial for the diagnosis of STEMI, but is also useful for the assessment of MVO. In this review we summarize ECG-derived parameters associated to MVO and their prognostic relevance.

Role of cardiac magnetic resonance imaging in identifying infarct related artery and non-ischemic pathogenesis in patients presenting with non ST elevation myocardial infarction.

INTRODUCTION: Identifying an Infarct-related artery (IRA)in Non-STEMI is sometimes tricky. Besides, myocardial infarction with non-obstructive coronary arteries (MINOCA) mimickers are often labeled as myocardial infarction. Late Gadolinium enhancement (LGE) on cardiac MRI can help in identifying IRA besides MINOCA mimickers. AIMS: To study the role of LGE on cardiac MRI(CMR) in NSTEMI. MATERIAL METHODS: It was a prospective observational, double-blinded study. 70 NSTEMI patients were prospectively enrolled over two years. CMR was done before coronary angiography (CAG) during the index hospitalization. Matching was done between IRA selected by CAG and IRA as determined by LGE on MRI. RESULTS: Mean age was 58 ± 15 years. CAG could not identify IRA in 38.6% (n = 27) patients. In this patient group, LGE-CMR identified IRA in 48.1% (n = 13) & a new non-CAD diagnosis was identified in 18.5% (n = 5) patients. IRA was identified in 61.4% (n = 43) by CAG & in this patient group, LGE-CMR identified a different IRA in 6.9% (n = 3) patients. LGE-CMR also identified a new non-CAD diagnosis in 11.6% (n = 5) of patients from this group. Overall, LGE-CMR led to a new IRA diagnosis in 23% (n = 16) patients & a diagnosis of non-ischemic pathogenesis in 14% (n = 10) patients. Non-Ischemic diagnosis on CMR included stress cardiomyopathy in 3, myocarditis in 6, and infiltrative disorder in 1 patient. CONCLUSION: CMR leads to new IRA diagnoses or non-ischemic pathogenesis in one-third of the cohort.