Late primary angioplasty (beyond 12 h): are we sure it should be avoided?

Optimal management for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a hospital late remains uncertain since evidence and real-world data are limited. Patients who present late with a STEMI are a heterogeneous population, and the clinical decision regarding percutaneous coronary intervention (PCI) should not be the same for all. One randomized clinical trial, multiple mechanistic studies, and contemporary registries suggest a presumed benefit for a prompt restoration of coronary flow even in late presenting STEMI. Crucial elements in decision-making are the presence of haemodynamic or electrical instability, and ongoing ischaemic signs or symptoms to tip the scales toward PCI. Among clinically stable, late-presenting patients, myocardial viability assessment and functional testing can identify yet another subgroup that may benefit from late PCI.

The time to reversal of complete atrioventricular block and its predictors in acute ST-segment elevation myocardial infarction.

OBJECTIVE: The purpose of this study was to determine the time to reversal of complete AV block (CAVB) in ST-segment elevation myocardial infarction (STEMI) with various modalities of treatment and to examine the factors associated with early reversal of CAVB. METHODS: We prospectively assessed the STEMI patients complicated by CAVB. The mean time to reversal of CAVB was analyzed and compared according to the treatment received. Multivariate logistic regression analysis was performed to find the predictors of mortality. RESULTS: Of 3954 patients with STEMI, CAVB was present in 146(3.7%) patients. Inferior wall myocardial infarction (IWMI) was more commonly associated with CAVB than anterior wall myocardial infarction (AWMI) (74.7% vs 25.3%). The mean time to reversal of CAVB was 25.4 ± 35.5 h. It was significantly lower with the primary percutaneous coronary intervention (PCI) compared to thrombolysis (5.21 ± 10.54 vs 12.98 ± 17.14; p = 0.0001). Predictors of early reversal of CAVB were early presentation to hospital (<6 h) from symptom onset, presence of IWMI, any revascularization done, primary PCI performed in comparison to thrombolysis, and normal serum creatinine levels. The presence of older age, broader QRS complex, cardiogenic shock/heart failure, and elevated creatinine were independent predictors of mortality. The CAVB reverted in all the alive patients except one who required permanent pacemaker implantation. CONCLUSION: CAVB is uncommon in STEMI and it recovers in a vast majority of surviving patients. The time to reversal of CAVB in STEMI is lower with primary PCI compared to thrombolysis. Outcomes are poor without revascularization in such patients.

The predictive role of modified TIMI risk index in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The prognostic value of thrombolysis in myocardial infarction (TIMI) risk index (TRI) has been reported in patients with coronary artery disease. In this study, we evaluated the additional prognostic value of blood urea nitrogen (BUN) level to the TRI in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We evaluated the in-hospital and long-term (3-year) prognostic value of modified TRI (mTRI) in patients with STEMI. The mTRI is calculated using the following equation; mTRI = (TRI × BUN)/10. Patients were stratified into 5 groups according to 20-point increments of mTRI. RESULTS: The patients with higher mTRI had significantly higher in-hospital and long-term mortality. The risk for in-hospital and long-term mortality was highest for those within the Q5 (36.8 and 42.3%, respectively) and it was significantly higher than all the other groups (p < .001 for both). CONCLUSIONS: In this study, the prognostic value of TRI has been augmented by multiplication of TRI with BUN/10. Therefore, we present a pilot study of association of mTRI with overall STEMI patients.

Efficacy of Nicorandil in Preventing Myocardial Injury and Cardiovascular Outcomes in Patients Undergoing Percutaneous Coronary Intervention (PCI): A Systematic Review and Meta-Analysis.

Percutaneous coronary intervention (PCI) is a common procedure for treating coronary artery disease, but it carries a risk of periprocedural myocardial injury (PMI). This meta-analysis evaluated the efficacy of nicorandil, a hybrid compound with nitrate-like and potassium channel-opening properties, in preventing PMI during PCI. A comprehensive literature search identified 14 studies involving 1,762 patients, with 882 receiving nicorandil and 880 in the control group. The analysis revealed that nicorandil significantly reduced the incidence of PMI (RR: 0.73, 95% CI: 0.61-0.86) and major adverse cardiovascular events (MACE) (RR: 0.76, 95% CI: 0.58-0.99) compared to the control group. Nicorandil's cardioprotective effects are attributed to its ability to improve coronary blood flow, precondition the myocardium, and reduce oxidative stress and inflammation. These findings suggest that nicorandil could be a valuable adjunctive therapy during PCI, potentially improving patient outcomes. However, the study had limitations, including variations in drug administration methods and a lack of individual-level data for subgroup analysis. Future research should focus on optimizing dosing regimens and administration timing and comparing nicorandil's effectiveness with other cardioprotective agents.

Dual Coronary Artery Thrombosis: An Unforeseen Angiographic Encounter.

Acute myocardial infarction (AMI) frequently involves single-vessel coronary artery disease, but simultaneous thrombosis in multiple coronary arteries is a rare and challenging clinical scenario. We report the case of a 42-year-old Southeast Asian male with a six-month history of hypertension controlled by a single antihypertensive agent, presenting to the emergency department with central chest pain radiating to the back. The initial electrocardiography (ECG) showed ST elevation in the inferior leads. Primary percutaneous coronary intervention (PCI) via the right femoral approach revealed complete thrombotic occlusions in the left anterior descending (LAD) and right coronary artery (RCA). Drug-eluting stents (DES) were deployed, restoring thrombolysis in myocardial infarction (TIMI) III flow. Despite initial hemodynamic stability, the patient experienced cardiogenic shock (CS), necessitating a relook angiogram that confirmed patent stents and identified an additional stenosis in the first diagonal branch (D1). An intra-aortic balloon pump (IABP) was inserted. The patient's course was complicated by recurrent CS, septic shock secondary to Fusobacterium periodonticum bacteremia, acute kidney injury, multiple supraventricular arrhythmias (SVTs), and partial thrombosis of the right radial artery leading to dry gangrene of the right index and thumb fingers. He was eventually discharged on oral warfarin for radial artery thrombosis and paroxysmal atrial fibrillation with follow-up care with vascular surgery.

A novel therapy in microvascular obstruction in ST-elevation myocardial infarction: pressure-controlled intermittent coronary sinus occlusion therapy.

Percutaneous coronary intervention has transformed the management of ST-elevation myocardial infarction (STEMI) due to a reduction in early mortality and need for repeat revascularization. However, the conventional revascularization strategy, combined with state-of-the-art anti-thrombotic and antiplatelet therapies, can still be associated with poor clinical outcome in some patients, because of reperfusion injury and microvascular obstruction contributing to the infarct size. To address this important therapeutic need, a broad-range of device-based treatments have been introduced. This is an overview of the pressure-controlled intermittent coronary sinus occlusion (PiCSO) device (Miracor Medical SA) which has been proposed for STEMI patients. PiCSO therapy could lead to an improved perfusion, decrease microvascular dysfunction, and thus potentially reduce infarct size.

'Routine intravascular ultrasound evaluation and change in stenting strategy in primary percutaneous intervention (RIST PCI)'.

BACKGROUND: Intravascular ultrasound (IVUS) provides better assessment of vessel size, lesion length and plaque characteristics. There is paucity of data regarding the impact of IVUS on stenting pattern during primary percutaneous intervention (PCI) for ST elevation myocardial infarction (STEMI). METHODS: We included patients with STEMI undergoing IVUS-guided primary PCI. Diagnostic angiograms were analysed by two different operators who were not part of procedure. They were asked to formulate a treatment plan which included choice of stent diameters, length and number of stents based on angiographic assessment alone. The data were then compared with actual metrics derived from IVUS evaluation. RESULTS: Sixty-two patients were included. Left anterior descending artery was involved in 38/62(61.3%) cases. Mean stent diameters assessed by angiogram were 2.94 ± 0.4 mm and 3.01 ± 0.32 mm by cardiologist 1 and 2, respectively. IVUS-derived mean stent diameter was 3.5 ± 0.65 mm (p < 0.001). Mean stent length was 42.29 ± 19.29 mm by IVUS evaluation; while angiographically assessed values were 33.53 ± 11.53 (cardiologist 1) and 35.24 ± 12.97 mm (cardiologist 2) with a mean difference of 8.76 mm and 7.05 mm respectively (p < 0.001). Mean number of stents by IVUS evaluation was 1.42 ± 0.56, while by angiographic evaluation were 1.11 ± 0.37 and 1.13 ± 0.34 respectively (p < 0.001). CONCLUSIONS: There was significant difference between IVUS derived and angiographically assessed culprit vessel metrics in patients undergoing primary PCI. Clinical outcomes of this discrepancy need further studies.

Diagnosis and Treatment of a Morel-Lavallée Lesion in the Lateral Knee With Point-of-Care Ultrasonography.

A 14-year-old male presented to the sports medicine clinic for evaluation of right lateral knee pain for three weeks after he took a forceful blow to his right lateral knee during a football game. He reported swelling and bruising and increasing pain since then. Physical exam was significant for an area of fluctuance that was approximately 20 cm in length and 10 cm in width overlying the lateral right knee with associated ecchymosis and decreased sensation. The remainder of the exam was benign. Point-of-care ultrasound showed a large hypoechoic space overlying the lateral knee consistent with a Morel-Lavallée lesion (MLL). Twenty-six milliliters of serosanguinous fluid were aspirated from between the fascial planes, deep to subcutaneous fat but superficial to quadriceps muscles, under ultrasound guidance. The lesion was sclerosed with 1 cc 1% lidocaine without epinephrine and 4 cc dexamethasone 4 mg/mL, and the patient was given compression wrappings to wear for the next four weeks. MLLs are collections of fluid that occur between different planes of subcutaneous tissue following blunt force or shearing trauma. The general mechanism of injury is a closed degloving injury that occurs following damage to the potential space between layers of fascia, dermis, and subcutaneous fat. MLLs are relatively rare lesions and, when identified, are most frequently found in the proximal thigh and associated with serious underlying bony fractures. MLLs are uncommon and difficult to diagnose due to their nonspecific findings of fluctuance, pain, and bruising. This case is unique in its presentation of an isolated MLL in the lateral knee. Early diagnosis and intervention of these lesions prevent further sequelae.

Applicability of left distal radial artery access site in ST-segment elevation myocardial infarction; A comparative evaluation with the conventional transfemoral approach.

BACKGROUND: Left distal radial artery (LDRA) has got high popularity as an alternative safe access site in coronary angiography. However, little is known about its applicability in primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) patients. We aimed to assess the convenience of LDRA access in STEMI patients and make the comparative evaluation with the transfemoral (TF) route. MATERIALS AND METHODS: A total of 91 consecutive STEMI patients who underwent PPCI from January to June 2019, were analyzed. Experienced operators, unaware of the study were left free of access site decision. Comparative demographic features and clinical outcomes were recorded during hospitalization. RESULTS: LDRA was used in 30 patients, whereas 61 patients underwent a TF approach. Successful PPCI was achieved in high rates in both groups (LDR: 90% vs TF: 91.8%: p = 0.795). On admission, KILLIP (II, III) class was higher in the LDRA group (23.3% vs 3.4%), whereas stent thrombosis, arhythmias were higher in the TF group (0% vs 6.6% p = 0.151; 6.7% vs 18% p = 0.355 respectively). Puncture time was relatively similar between groups (28.63 vs 28.93 s p = 0.767). Fluoroscopy time, total radiation exposure and hospital duration was found lower in the LDRA group (10.11 vs 13.75 min p < 0.001; 917.87 vs 1940.91 mGy p < 0.001; 4.2 vs 6.2 days p = 0.024 respectively). In-hospital mortality was found higher in the TF group (0% vs 18% p = 0.013). CONCLUSION: In the acute management of STEMI, LDRA access site can be a convenient alternative to TF approach with shorter hospital duration and complication rates.

The Impact of COVID-19 on In-Hospital Outcomes of ST-Segment Elevation Myocardial Infarction Patients.

Primary percutaneous coronary intervention (PPCI) is one of the important clinical procedures that have been affected by the COVID-19 pandemic. In this study, we aimed to assess the incidence and impact of COVID-19 on in-hospital clinical outcome of ST elevation myocardial infarction (STEMI) patients managed with PPCI. This observational retrospective study was conducted on consecutive STEMI patients who presented to the International Cardiac Center (ICC) hospital, Alexandria, Egypt between 1 February and 31 October 2020. A group of STEMI patients presented during the same period in 2019 was also assessed (control group) and data was used for comparison. The inclusion criteria were established diagnosis of STEMI requiring PPCI.A total of 634 patients were included in the study. During the COVID-19 period, the number of PPCI procedures was reduced by 25.7% compared with previous year (mean 30.0 ± 4.01 vs. 40.4 ± 5.3 case/month) and the time from first medical contact to Needle (FMC-to-N) was longer (125.0 ± 53.6 vs. 52.6 ± 22.8 min, p = 0.001). Also, during COVID-19, the in-hospital mortality was higher (7.4 vs. 4.6%, p = 0.036) as was the incidence of re-infarction (12.2 vs. 7.7%, p = 0.041) and the need for revascularization (15.9 vs. 10.7%, p = 0.046). The incidence of heart failure, stroke, and bleeding was not different between groups, but hospital stay was longer during COVID-19 (6.85 ± 4.22 vs. 3.5 ± 2.3 day, p = 0.0025). Conclusion: At the ICC, COVID-19 pandemic contributed significantly to the PPCI management of STEMI patients with decreased number and delayed procedures. COVID-19 was also associated with higher in-hospital mortality, rate of re-infarction, need for revascularization, and longer hospital stay.

New Interventional Therapies beyond Stenting to Treat ST-Segment Elevation Acute Myocardial Infarction.

Myocardial infarction remains the principal cause of death in Europe. In patients with ST-segment-elevation myocardial infarction (STEMI), a promptly revascularization with primary percutaneous intervention (PCI) has transformed prognosis in the last decades. However, despite increasing successful PCI procedures, mortality has remained unchanged in recent years. Also, due to an unsatisfactory reperfusion, some patients have significant myocardial damage and suffer left ventricular adverse remodeling with reduced function-all that resulting in the onset of heart failure with all its inherent clinical and socioeconomic burden. As a consequence of longer ischemic times, distal thrombotic embolization, ischemia-reperfusion injury and microvascular dysfunction, the resultant myocardial infarct size is the major prognostic determinant in STEMI patients. The improved understanding of all the pathophysiology underlying these events has derived to the development of several novel therapies aiming to reduce infarct size and to improve clinical outcomes in these patients. In this article, based on the mechanisms involved in myocardial infarction prognosis, we review the new interventional strategies beyond stenting that may solve the suboptimal results that STEMI patients still experience.

Current Practice of Percutaneous Coronary Intervention in Patients With Coagulation Disorders.

Acute coronary artery disease represents the leading cause of death worldwide. Some studies have shown that coagulation disorders can play a protective role against ischemic heart disease, presumably due to hypocoagulable state and decrease thrombin formation. However, autopsy reports showed atherosclerotic lesions in some patients with hemophilia. Since the introduction of clotting factors and replacement therapies, the life expectancy of patients with coagulation disorders has increased significantly. As a result, the incidence of cardiovascular diseases became higher making their treatment more challenging. Door to balloon strategy applies in ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention should not be delayed. While in non-STEMI (NSTEMI) and unstable angina, a hematology consult is essential. Prophylactic coagulation factor replacement is crucial in these patients in order to avoid bleeding complications, but on the other hand, these factors were also associated with thrombotic complications. Historically, bare-metal stents were preferred over drug-eluting stents in view of the shorter duration of dual antiplatelets therapy (DAPT). Currently, some trials have demonstrated the safety of new-generation drug-eluting stents in patients with elevated bleeding risk, where DAPT use is limited to four weeks. The radial artery is the preferred access and was found to have less bleeding complications when compared to the femoral access. Anticoagulation with heparin is the safest in view of antidote availability and shorter half-life. Bivalirudin has also been used in some case reports, while GP2b3a inhibitors are usually avoided except in a high thrombus burden. Close peri procedural follow-up is important with patient education about symptoms of bleed. Carefully and individually tailored antithrombotic and factor replacement therapy is required to overcome these clinically challenging situations. Early screening for cardiovascular risk factors and considering early intervention and management might help to improve the general health status of this population and reduce morbidity.

Impact of the shift to a fibrinolysis-first strategy on care and outcomes of patients with ST-segment-elevation myocardial infarction during the COVID-19 pandemic-The experience from the largest cardiovascular-specific centre in China.

BACKGROUND: The impact of fibrinolysis-first strategy on outcomes of patients with ST-segment-elevation myocardial infarction (STEMI) during the COVID-19 pandemic was unknown. METHODS: Data from STEMI patients presenting to Fuwai Hospital from January 23 to April 30, 2020 were compared with those during the equivalent period in 2019. The primary end-point was net adverse clinical events (NACE; a composite of death, non-fatal myocardial reinfarction, stroke, emergency revascularization, and bleeding over BARC type 3). The secondary outcome was a composite of recurrent ischaemia, cardiogenic shock, and exacerbated heart failure. RESULTS: The final analysis included 164 acute STEMI patients from 2020 and 240 from 2019. Eighteen patients (20.2% of those with indications) received fibrinolysis therapy in 2020 with a median door-to-needle time of 60.0 (43.5, 92.0) minutes. Patients in 2020 underwent primary PCI less frequently than their counterparts (14 [14.2%] vs. 144 [86.8%] in 2019, P < 0.001), and had a longer median door-to-balloon time (175 [121,213] minutes vs. 115 [83, 160] minutes in 2019, P = 0.009). Patients were more likely to undergo elective PCI (86 [52.4%] vs. 28 [11.6%] in 2019, P < 0.001). The in-hospital NACE was similar between 2020 and 2019 (14 [8.5%] vs. 25 [10.4%], P = 0.530), while more patients developed a secondary outcome in 2020 (20 [12.2%] vs. 12 [5.0%] in 2019, P = 0.009). CONCLUSIONS: The fibrinolysis-first strategy during the COVID-19 pandemic was associated with a lower rate of timely coronary reperfusion and increased rates of recurrent ischaemia, cardiogenic shock, and exacerbated heart failure. However, the in-hospital NACE remained similar to that in 2019.

Primary PCI for acute myocardial infarction in a patient with situs inversus totalis and dextrocardia.

Situs inversus totalis with dextrocardia is a rare congenital occurrence. Risk of coronary atherosclerosis and acute myocardial infarction in this subset is similar to that in the general population. Diagnosing myocardial injury in time, and executing primary percutaneous coronary intervention (PCI) successfully in these patients is challenging given that physicians are rarely attuned to recognizing the electrocardiographic changes of acute coronary syndromes in this anatomy and interventional cardiologists are not routinely accustomed to working with the angiographic projections in this unique subset. Here, we describe electrocardiogram identification and an approach to primary PCI in one such patient. We have also attempted to simplify and refine primary PCI in this subset by introducing postero-anterior projection single inversion technique for suitable lesions in suitable vessels in this unique subset. .

In-Hospital Mortality Risk in Post-Percutaneous Coronary Interventions Cancer Patients: A Nationwide Analysis of 1.1 Million Heart Disease Patients.

Objectives The primary goal of this inpatient study is to assess the risk of in-hospital mortality due to cancer and chronic comorbidities in post-percutaneous coronary intervention (PCI) patients. Methods We conducted a retrospective cross-sectional study, including 1,131,415 adult patients (age +18 years) by using the Nationwide Inpatient Sample (NIS) from 2012 to 2014. These patients underwent PCI, and they were further sub-grouped by the co-diagnosis of cancer. Logistic regression analysis was used to evaluate the risk of association between comorbid cancer and in-hospital mortality in post-PCI inpatients. Results Most PCI inpatients with cancer were older adults (mean age 70.6 years), males (71.8%), and white (80.6%). Post-PCI mortality risk was 1.28 times higher in females (95% CI 1.235 - 1.335) as compared to males. Coagulopathy and anemias significantly increased the risk of post-PCI mortality by three times (95% CI 2.837 - 3.250) and 1.6 times (95% CI 1.534 - 1.692), respectively. Comorbid cancer was associated with an increased risk of in-hospital mortality in post-PCI patients by 1.9 times (95% CI 1.686 - 2.086) after controlling for demographic confounders and chronic comorbidities. Conclusion Our analysis showed that cancer is an independent risk factor for in-hospital mortality after PCI. This association calls for an integrated care model in the management of a complex patient population with cancer and other comorbidities requiring more vigilance and aggressive management.

Acute and sub-acute stent thrombosis: Frequency, predictors and features in patients undergoing primary percutaneous intervention at a tertiary care cardiac centre.

OBJECTIVES: To assess the frequency of early (acute and sub-acute) stent thrombosis (ST) after primary percutaneous coronary intervention (pPCI) and to identify its potential predictors. BACKGROUND: ST is a serious clinical event associated with a high mortality rate. A very limited data are available regarding the incidence rate of early ST after pPCI and its predictors, especially for Pakistani population. METHODS: Study included consecutive patients who underwent primary PCI. Telephonic follow-ups were made to obtain 30-days outcomes including ST, mortality, and re-occurrence of symptoms. ST was defined as per the standardized definition proposed by the Academic Research Consortium and classified as acute (during the procedure) and sub-acute (within 30 days). RESULTS: A total of 569 patients were included with 80.5% (485) male patients. The stent thrombosis (acute or sub-acute) was observed in 33 (5.8%) patients out of which 3 (9.1%) were definite ST while remaining 30 (90.9%) were probable ST. Patients who develop ST were predominantly male, hypertensive, diabetic, with reduced pre PCI LVEF (%) and Killip Class. A significantly higher in-hospital mortality rate was observed in patients with ST as compared to without ST, 36.4% (12/33) vs. 0.2% (1/536); p-value < 0.001 respectively. Killip Class (III-IV) was found to be the independent predictor of ST with an adjusted odds ratio of 5.2 [1.76-15.32]. CONCLUSIONS: Early stent thrombosis (ST) is relatively frequent in patients undergoing primary PCI. Diabetic and hypertensive patients are at an increased risk of ST and presentation of patients in Killip Class III-IV is an independent predictor of early ST.

Left Distal Radial Artery Access Site in Primary Percutaneous Coronary Intervention: Is It Safe?

Background: Left distal radial artery access site has emerged as a new technique for coronary angiography procedures. Aims: We aimed at assessing its applicability as an alternative way for primary percutaneous coronary interventions in ST-elevation myocardial infarction. Study Design: Retrospective observational cohort study. Methods: Left distal radial artery was used as an access site in 30 consecutive ST-elevation myocardial infarction patients for primary coronary intervention. It was used by experienced operators who were unaware of the study. All patients had a prominent pulse in their left forearm and distal radial artery. Each patient's left arm was gently bent into his/her right groin with comfortable position of the hand. The operator/s stood at the right side of the patient where both could make the arterial puncture. Demographic features and complications were recorded during the hospital stay. Results: Mean age of patients was 58 years with a male gender predominance of 87%. Fifteen patients were diagnosed of Inferior elevation myocardial infarction, 14 patients of Anterior, and one of Lateral elevation myocardial infarction. The most common culprit artery was the left anterior descending coronary artery (14 patients). Six patients were in KILLIP class II on admission and only one with Anterior elevation myocardial infarction was in severe pulmonary edema (KILLIP III) during intervention. All the procedures were successfully contemplated with 6 French Judkins catheters. Brachial spasm occurred in one patient which was resolved with intra-arterial nitrate. Transfemoral approach was changed to left distal radial access in 4 patients due to severe bilateral iliac artery disease. Mean puncture time was 37.36 seconds. There was no radial occlusion, hematoma, hand neurologic deficit or bleeding. Patients were discharged on an average duration of 4.2 days. Conclusion: Left distal radial artery can be used as an alternative safe and feasible access site for successful primary coronary interventions provided that it is performed by experienced operators.

Diurnal Variation in Outcomes of Percutaneous Coronary Intervention.

Objectives To determine whether the outcomes differ during regular hours as compared to off hours in patients with acute myocardial infarction who undergo primary percutaneous coronary intervention. Methods We conducted a prospective, interventional study of patients who presented to a specialized cardiac care center. Patients who satisfied the inclusion and exclusion criteria were included in the study. They were divided into two groups so that one group received intervention during regular working hours while the other group received intervention during 'off' hours. The data was collected through a self-constructed questionnaire. Cronbach's alpha was used to assess the internal consistency of the questionnaire, and it was found to be 0.75. The data obtained was analyzed on IBM's Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM, Armonk, NY). Results Out of 100 participants, 64 (64%) were males and 36 (36%) were females. The mean age of the participants was 58.58 ± 13.21 years. Most (44%) of the patients were diabetic. Inferior wall myocardial infarcts were more common in our study. Percutaneous intervention during 'off' hours was associated with more adverse outcomes. The differences in gender and angina requiring revascularization were statistically significant (p-value<0.05). Conclusion No significant difference in outcomes was observed in both groups of patients. Metacentric data from different institutes should be gathered for a comprehensive insight on this topic where door-to-balloon times and initiation of catheterization lab procedures are practiced in different ways.

Entrapment of a Partially Degloved Stent in the Radial Artery: is there Any Way Out?

Stent loss during percutaneous coronary intervention (PCI) is uncommon but may lead to serious adverse events. Here we describe a challenging case of stent loss in the radial artery during primary PCI. There, a long stent failed to cross the culprit lesion, and an attempt to pull back the undeployed stent into the guiding catheter resulted in eversion of the stent, partially stripping it off the stent balloon and rendering the stent irretrievable. Retrieval of the stent at all costs might have led to major complications; hence stent deployment in the radial artery bailed us out of this precarious situation.

Acute ST-Elevation Myocardial Infarction Before and During the COVID-19 Pandemic: What is the Clinically Significant Difference?

Background In the current coronavirus disease-2019 (COVID-19) pandemic, the pattern of hospital admissions for acute ST-elevation myocardial infarction (STEMI) is changing, and increased mortality and morbidity is being noted in these patients. Cardiac manifestations of COVID-19 are complex and include STEMI, myocarditis, myocardial injury, and cardiomyopathy. The objective of our study was to compare the data of patients with STEMI presenting in COVID-19 versus the non-COVID-19 era.  Methods We analyzed the clinical and angiographic characteristics of STEMI patients undergoing primary percutaneous coronary intervention (PCI) at our center. The primary outcome variables were admission rate for STEMI, mean total ischemic time (TIT), coronary artery disease burden, mean ejection fraction, and in-hospital mortality for three defined groups. Group A consisted of patients who underwent primary PCI from March through April 2020. Group B included patients who underwent primary PCI from January to February 2020. Group C consisted of patients who underwent primary PCI from March to April 2019. We then compared the data among the three groups and calculated any significant p-value (p<.001). Results In Group A, 1139 patients were admitted for primary PCI. The mean admission rate was 18.6 ± 4.36 admissions per day. There were 1535 patients in Group B and an admission rate of 26.01 ± 4.90 (p<.001 compared to Group A). In Group C, there were 1537 patients and an admission rate of 24.8 ± 4.55 (p<.001, compared to Group A). The mean TIT was 429.25±272.16 minutes for Group A, 359.78±148.04 minutes for Group B, and 346.75±207.31 minutes for Group C (p<.001). A higher mortality rate was noted in Group A (COVID-19 era) versus Group C (non-COVID-19 era; p<.001). Conclusions A lower admission rate, higher TIT, and higher mortality rates were noted in patients with acute STEMI during the COVID-19 pandemic compared to the pre-COVID era. During the COVID-19 pandemic, physicians should bear in mind that patients with STEMI have increased mortality and morbidity. Where possible, efforts should be made for timely management of these critical patients to decrease mortality.