Interhospital Transfer versus Direct Admission in Patients with Acute ST-Segment Elevation Myocardial Infarction.

There is concern whether patients with ST-segment elevation myocardial infarction (STEMI) who admitted to a percutaneous coronary intervention (PCI) center from interhospital transfer is associated with longer reperfusion time compared with direct admission. We evaluated the reperfusion delays in patients with STEMI who admitted to a primary PCI center through interhospital transfer or direct admission. We retrospectively analyzed 6,494 consecutive STEMI patients admitted between 2011 and 2019. Compared with direct admission ( n = 4,121; 63%), interhospital transferred patients ( n = 2,373) were younger (55 ± 10 vs. 56 ± 10 years, p < 0.001), had similar gender (85.6 vs. 86% male, p = 0.67), greater proportion of off-hour admission (65.2 vs. 48.3%, p < 0.001), less diabetes mellitus (28 vs. 30.8%, p = 0.019), and received more primary PCI (70.5 vs. 48.7%, p < 0.001). Interhospital transferred patients who received primary PCI ( n = 3,677) or fibrinolytic ( n = 238) had longer symptom-to-PCI center admission time (median, 360 vs. 300 minutes, p < 0.001), shorter door-to-device (DTD) time for primary PCI (median, 74 vs. 87 minutes, p < 0.001), and longer total ischemic time (median, 465 vs. 414 minutes, p < 0.001). Logistic regression in interhospital transferred patients showed that delay in door-in-to-door-out (DI-DO) time at the first hospital was strongly associated with prolonged total ischemic time (adjusted odds ratio = 3.92; 95% confidence interval: 3.06-5.04, p < 0.001). This study suggests that although interhospital transferred patients received more primary PCI with shorter DTD time, interhospital transfer creates longer total ischemic time that associates with the delay in DI-DO time at the first hospital that should be improved.

A Novel Peptide Elabela is Associated with Hypertension-Related Subclinical Atherosclerosis.

INTRODUCTION: Elabela is a newly identified peptide which, alongside apelin, acts as an endogenous ligand that activates the angiotensin receptor-like 1 receptor. Previous studies have shown the association of elabela with hypertension, but information about the role of elabela in hypertension-related subclinical atherosclerosis is scarce. AIM: We aimed to determine the elabela levels in hypertensive patients and explore its association with subclinical atherosclerosis. METHODS: A total of 104 subjects with hypertension were included in the study. Elabela levels were measured using an enzyme-linked immunosorbent assay, by first extracting the peptide following the manufacturer's instructions. Subclinical atherosclerosis was assessed by measuring the carotid intima-media thickness (IMT) using ultrasound. RESULTS: Compared to stage 1, elabela levels decreased in stage 2 hypertension (0.23 [0.13, 0.45] ng/ml vs. 0.14 [0.09, 0.23] ng/ml; P = 0.000), and in the group with increased carotid IMT compared to normal IMT (0.24 [0.13, 0.38] ng/ml vs. 0.15 [0.10, 0.23] ng/ml; P = 0.005). Additionally, a linear correlation analysis showed that elabela had a significant negative correlation with systolic blood pressure (r = - 0.340, P = 0.000) and carotid IMT (r = - 0.213; P = 0.030). In multivariate analysis, lower elabela levels were associated with a higher cardiovascular risk group in this study (OR 5.0, 95% CI 1.8-13.5, P < 0.001). CONCLUSIONS: This study demonstrated for the first time that circulating elabela declined in a higher stage of hypertension and hypertensive patients with increased carotid IMT, implicating that elabela may be involved in the pathogenesis of hypertension-associated subclinical atherosclerosis.

Skin Mottling as Clinical Manifestation of Cardiogenic Shock.

A 59 years old male came to the emergency department with chief complain of dyspnea. Dyspnea has worsened since 3 days before admission accompanied with dyspnea on effort, orthopnea and paroxysmal nocturnal dyspnea. In the emergency department, patient experienced cardiac arrest after defecating, leading to cardiopulmonary resuscitation for 45 minutes. Administration of vasoactive drugs were done and the patient was intubated.Post resucitaiton physical examination showed that the patient was sedated, with blood pressure of 72/40 (on dobutamine support). Peripheral circulation examination showed cold and clammy extremities, skin mottling of the lower extremity with mottling score of 2. CRT is more than 2 seconds. Blood gas analysis showed severe metabolic acidosis with blood lactate of 8.1.Angiographic examination were previously done on the patient during the previous admission with the results of three vessels disease with a chronic total occlusion in the left anterior descending artery. However, patient had refused further intervention regarding the coronary problems. Patient also has longtsanding atrial fibrillation.Patient was admitted into the intensive care unit for further management. Patient was stabilized during admisison in the intensive care with inotropes, however despite the hemodynamic stablilization the skin remain mottled-regardless. Patient had complicating factors in the form of pneumonia and sepsis. Patient had difficulty in weaning the ventilator and died because of arrythmia complication.

2020 Asian Pacific Society of Cardiology Consensus Recommendations on Antithrombotic Management for High-risk Chronic Coronary Syndrome.

The unique characteristics of patients with chronic coronary syndrome (CCS) in the Asia-Pacific region, heterogeneous approaches because of differences in accesses and resources and low number of patients from the Asia-Pacific region in pivotal studies, mean that international guidelines cannot be routinely applied to these populations. The Asian Pacific Society of Cardiology developed these consensus recommendations to summarise current evidence on the management of CCS and provide recommendations to assist clinicians treat patients from the region. The consensus recommendations were developed by an expert consensus panel who reviewed and appraised the available literature, with focus on data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting recommendations provide guidance on the assessment and management of bleeding and ischaemic risks in Asian CCS patients. Furthermore, the selection of long-term antithrombotic therapy is discussed, including the role of single antiplatelet therapy, dual antiplatelet therapy and dual pathway inhibition therapy.

Performance of Primary Angioplasty for STEMI during the COVID-19 Outbreak.

There has been concern whether the declining cases of ST-segment elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) outbreak associate with primary angioplasty performance. We assessed the performance of primary angioplasty in a tertiary care hospital in Jakarta, Indonesia, by comparing the door-to-device (DTD) time and thrombolysis in myocardial infarction (TIMI) flow after angioplasty between two periods of admission: during the outbreak of COVID-19 (March 1 to May 31, 2020) and before the outbreak (March 1, to May 31, 2019). Overall, there was a relative reduction of 44% for STEMI admission during the outbreak ( n = 116) compared with before the outbreak ( N = 208). Compared with before the outbreak period ( n = 141), STEMI patients who admitted during the outbreak and received primary angioplasty ( n = 70) had similar median symptom onset-to-angioplasty center admission (360 minutes for each group), similar to radial access uptake (90 vs. 89.4%, p = 0.88) and left anterior descending infarct-related artery (54.3 vs. 58.9%, p = 0.52). The median DTD time and total ischemia time were longer (104 vs. 81 minutes, p < 0.001, and 475.5 vs. 449 minutes, p = 0.43, respectively). However, the final achievement of TIMI 3 flow was similar (87.1 vs. 87.2%), and so was the in-hospital mortality (5.7 vs. 7.8%). During the COVID-19 outbreak, we found a longer DTD time for primary angioplasty, but the achievement of final TIMI 3 flow and in-hospital mortality were similar as compared with before the outbreak. Thus, primary angioplasty should remain the standard of care for STEMI during the COVID-19 outbreak.

Increase in the risk of clopidogrel resistance and consequent TIMI flow impairment by DNA hypomethylation of CYP2C19 gene in STEMI patients undergoing primary percutaneous coronary intervention (PPCI).

Clopidogrel resistance is an important risk factor of ischemic event recurrence after optimal antiplatelet therapy. This study aims to investigate the role of CYP2C19 gene DNA methylation as one of the epigenetic factors for the risk of clopidogrel resistance in STEMI patients undergoing PPCI. ST-segment elevation myocardial infarction (STEMI) patients undergoing PPCI were pretreated with clopidogrel, and their platelet function was measured using VerifyNow™ assay. The criteria for high on-treatment platelet reactivity (HPR) were defined according to the expert consensus criteria (PRU >208). DNA methylation of the CYP2C19 gene was performed using bisulfite genomic sequencing technology. Furthermore, clinical, laboratory, and angiographic data including TIMI flow were collected. Among 122 patients, clopidogrel resistance was found in 22%. DNA methylation level percentage was lower in the clopidogrel resistance group (76.7 vs. 88.8, p-value .038). But, the <50% methylation group was associated with increased risk of clopidogrel resistance (OR =4.5, 95%CI =2.1-9.3, p-value = .018). This group was also found to have suboptimal post-PCI TIMI flow (OR =3.4 95%CI =1.3-8.7, p-value =.045). The lower DNA methylation level of the CYP2C19 gene increases the risk of clopidogrel resistance and subsequent poorer clinical outcome.

Association of gender with clinical outcomes of patients with acute ST-segment elevation myocardial infarction presenting with acute heart failure.

BACKGROUND: There is limited data evaluating the sex differences in outcomes of patients with ST-segment elevation myocardial infarction presenting with acute heart failure. We compared the outcomes between women and men with ST-segment elevation myocardial infarction presenting with acute heart failure (Killip classification ≥II). METHOD: All ST-segment elevation myocardial infarction patients presenting to the emergency department of a cardiovascular center in Jakarta, Indonesia, from 1 February 2011 to 30 August 2019 were retrospectively analyzed. RESULTS: Of 6557 patients recorded, 929 were women, and 276 (4.2%) presented with acute heart failure. Compared with men with acute heart failure (N = 1540), women who presented with acute heart failure were older (63 ± 10 vs. 57 ± 10 years, P < 0.001), had a greater proportion of thrombolysis in myocardial infarction risk score >4 (85% vs. 73%, P < 0.001), received fewer primary angioplasty and in-hospital fibrinolytic therapy (40% vs. 48%, P = 0.004 and 1.1% versus 3.5%, P = 0.03, respectively), and had longer median door-to-device and total ischemia times (96 vs. 83 minutes, P = 0.001, and 516 versus 464 minutes, P = 0.02, respectively). Multivariate analysis showed that women and men with acute heart failure were each associated with increased risk of in-hospital mortality (odds ratio: 4.70; 95% confidence interval: 3.28-6.73 and odds ratio: 4.75; 95% confidence interval: 3.84-5.88, respectively), and this remained relatively unchanged even among patients with acute heart failure who had undergone reperfusion therapy (odds ratio: 5.35; 95% confidence interval: 3.01-9.47 and odds ratio: 5.19; 95% confidence interval: 3.80-7.08, respectively). CONCLUSION: In our population, women with ST-segment elevation myocardial infarction presenting with acute heart failure had relatively similar risk of early mortality with their male counterpart (≈5-fold), thus should receive evidence-based treatment.

"Door-In to Door-Out" Delay in Patients with Acute ST-Segment Elevation Myocardial Infarction Transferred for Primary Percutaneous Coronary Intervention in a Metropolitan STEMI Network of a Developing Country.

Background Routine performance measures of primary percutaneous coronary intervention (PCI) within an ST-segment elevation myocardial infarction (STEMI) network are needed to improve care. Objective We evaluated the door-in to door-out (DI-DO) delays at the initial hospitals in STEMI patients as a routine performance measure of the metropolitan STEMI network. Patients and Methods We retrospectively analyzed the DI-DO time from 1,076 patients with acute STEMI who were transferred by ground ambulance to a primary PCI center for primary PCI between 4 October 2014 and 1 April 2019. Correlation analysis between DI-DO times and total ischemia time was performed using Spearman's test. Logistic regression analyses were used to find variables associated with a longer DI-DO time. Results Median DI-DO time was 180 minutes (25th percentile to 75th percentile: 120-252 minutes). DI-DO time showed a positive correlation with total ischemia time ( r = 0.4, p < 0.001). The median door-to-device time at the PCI center was 70 minutes (25th percentile to 75th percentile: 58-88 minutes). Multivariate analysis showed that women patients were independently associated with DI-DO time > 120 minutes (odds ratio 1.55, 95% confidence interval 1.03 to 2.33, p = 0.03). Conclusion The DI-DO time reported in this study has not reached the guideline recommendation. To improve the overall performance of primary PCI in the region, interventions aimed at improving the DI-DO time at the initial hospitals and specific threat for women patients with STEMI are possibly the best efforts in improving the total ischemia time.

Hospital outcomes in STEMI patients after the introduction of a regional STEMI network in the metropolitan area of a developing country.

Aims: Data on the long-term outcomes of STEMI patients treated via a network in Asian countries are very limited. We aimed to evaluate the characteristics and outcomes of STEMI patients at two different periods, before and five years after the establishment of a regional STEMI network in Jakarta, Indonesia. Methods and results: Out of 6,291 patients with STEMI admitted to hospital between January 2008 to January 2016, we compared the characteristics and outcomes of STEMI patients from two different periods, January 2008 to July 2009 (before instalment of the STEMI network, N=624), and from January 2015 to January 2016 (five years after the start of the network, N=1,052). The PCI hospital is an academic tertiary care cardiac hospital and initiated the regional STEMI network in 2010. Logistic regression was used to determine the adjusted association between treatment in the latter period and mortality. Compared with data from 2008/2009, in the 2015/2016 period, more primary PCI procedures were performed (N=589 [56%] vs. N=176 [28%], p<0.001), fewer patients did not receive reperfusion therapy (37% vs. 59%, p<0.001), and median door-to-device (DTD) times were shorter (82 vs. 94 minutes, p<0.001). Overall in-hospital mortality decreased from 9.6% to 7.1% (adjusted odds ratio 0.72, 95% CI: 0.50 to 1.03, p=0.07). Conclusions: Half a decade after the implementation of the STEMI network in Jakarta, Indonesia, the result is better and faster care for patients with STEMI and this has been associated with lower in-hospital mortality.

Heart failure across Asia: Same healthcare burden but differences in organization of care.

A gap in the knowledge on the status of heart failure (HF) in Asia versus other regions led to the creation of a working group of Asian experts from 9 countries or regions (Hong Kong, Indonesia, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam). Each expert sought the best available data from local publications, registries, or clinical practice. The prevalence of HF in Asia was generally similar to global values (1% to 3%), but with some outliers. There were substantial variations in healthcare spending, and the average cost of HF hospitalization varied from 813 US$ in Indonesia to nearly 9000 US$ in South Korea. Comorbidities were frequent, particularly hypertension, diabetes mellitus, and dyslipidemia. Modifiable risk factors such as smoking were alarmingly common in some countries. Asian HF patients spent between 5 and 12.5days in hospital, and 3% to 15% were readmitted for HF by 30days. The pharmacological treatment of Asian patients generally followed international guidelines, including renin-angiotensin-aldosterone system inhibitors (61% to 90%), diuretics (76% to 99%), beta-blockers (32% to 78%), and digoxin (19% to 53%), with some room for improvement in terms of life-saving therapies. Our review supports implementation of a more comprehensive and organized approach to HF care in Asia.

Impact of Timing of Eptifibatide Administration on Preprocedural Infarct-Related Artery Patency in Acute STEMI Patients Undergoing Primary PCI.

The appropriate timing of eptifibatide initiation for acute ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. This study aimed to analyze the impact of timing of eptifibatide administration on infarct-related artery (IRA) patency in STEMI patients undergoing primary PCI. Acute STEMI patients who underwent primary PCI (n = 324) were enrolled in this retrospective study; 164 patients received eptifibatide bolus ≤ 30 minutes after emergency department (ED) admission (group A) and 160 patients received eptifibatide bolus > 30 minutes after ED admission (group B). The primary endpoint was preprocedural IRA patency. Most patients in group A (90%) and group B (89%) were late presenters (> 2 hours after symptom onset). The two groups had similar preprocedural thrombolysis in myocardial infarction 2 or 3 flow of the IRA (26 vs. 24%, p = not significant [NS]), similar creatine kinase-MB (CK-MB) levels at 8 hours after admission (339 vs. 281 U/L, p = NS), similar left ventricular ejection fraction (LVEF) (52 vs. 50%, p = NS), and similar 30-day mortality (2 vs. 7%, p = NS). Compared with group B, patients in group A had shorter door-to-device time (p < 0.001) and shorter procedural time (p = 0.004), without increased bleeding risk (13 vs. 18%, p = NS). Earlier intravenous administration of eptifibatide before primary PCI did not improve preprocedural IRA patency, CK-MB level at 8 hours after admission, LVEF and 30-day mortality compared with patients who received intravenous eptifibatide that was administered later.

A Randomized Comparison between Everolimus-Eluting Stent and Cobalt Chromium Stent in Patients with Acute ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention Using Routine Intravenous Eptifibatide: The X-MAN (Xience vs. Multi-Link Stent in Acute Myocardial Infarction) Trial, A Pilot Study.

The objective of this study is to determine the efficacy and safety of an everolimus-eluting stent (EES/Xience; Abbott Vascular, Santa Clara, CA) compared with a cobalt chromium stent (CoCr/Multi-Link Vision; Abbott Vascular) in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with routine administration of eptifibatide infusion. This is a prospective, single center, randomized trial comparing EES (n = 75) and CoCr stent (n = 75) implantation in patients with acute STEMI undergoing primary PCI. Intravenous eptifibatide administration was mandatory by protocol in this pilot study. The primary efficacy endpoint was major adverse cardiac events (MACE) at 30 days, defined as the composite of death, reinfarction, and target vessel revascularization. Secondary safety endpoints were stent thrombosis at 30 days and in-hospital bleeding event. Acute reperfusion parameters were also assessed. One-month MACE rate did not differ between EES and CoCr group (1.3 vs. 1.3%, p = 1.0). No stent thrombosis cases were observed in the EES group. The groups did not differ with respect to in-hospital bleeding events (5 vs. 9%, p = 0.37), achievement of final thrombolysis in myocardial infarction flow 2 or 3 (p = 0.21), achievement of myocardial blush grade 2 or 3 (p = 0.45), creatine kinase-MB level at 8 to 12 hours after stenting (p = 0.29), and left ventricular ejection fraction (p = 0.21). This pilot study demonstrates that after one-month follow-up, the use of EES is as safe and effective as the use of CoCr stents in patients with acute STEMI undergoing primary PCI with routine administration of intravenous eptifibatide.

Temporal trends of system of care for STEMI: insights from the Jakarta Cardiovascular Care Unit Network System.

AIM: Guideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care. METHODS AND RESULTS: Between 2008-2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008-2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p<0.001), more primary percutaneous coronary intervention (PCI) procedures (83% vs 73%, p = 0.005), and more patients reaching door-to-needle time ≤ 30 minutes (84.5% vs 80.2%, p<0.001). However, numbers of patients who presented very late (>12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤ 90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008-2010. CONCLUSION: After a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤ 30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.

The Use of Intra-aortic Balloon Pump in a Real-World Setting: A Comparison between Survivors and Nonsurvivors from Acute Coronary Syndrome Treated with IABP. The Jakarta Acute Coronary Syndrome Registry.

Real-world data on acute coronary syndrome (ACS) patients who received intra-aortic balloon pump (IABP) support are limited. The objective of this study was to evaluate the characteristics of ACS patients who received IABP support from a real-world ACS registry. Patients with ACS (N = 121) who received IABP support were enrolled. Characteristics of survivors and nonsurvivors were compared at 30 days. Mortality rate of patients with ACS who received IABP was 47%. The survivors (N = 64) had less often cardiogenic shock (p < 0.001), more often IABP usage as back-up for a revascularization procedure (p = 0.002), less often resuscitation (p = 0.043), and less mechanical ventilator support (p < 0.001) than nonsurvivors. The nonsurvivors had a significantly higher leukocyte count (p = 0.033), a higher serum creatinine level (p < 0.001), a higher blood sugar on admission (p = 0.001), higher creatine kinase MB levels (p = 0.002), and a higher serum uric acid level (p < 0.001), but significantly lower left and right ventricular function (p = 0.014 and p = 0.003, respectively) than survivors. At 30 days, non-ST elevation (STE)-ACS patients had lower mortality rate than ST segment elevation myocardial infarction patients (log-rank test, p < 0.001), and non-STE-ACS patients who had not suffered from cardiogenic shock showed the lowest mortality rate (log-rank test, p < 0.001). By multivariate analysis, a heart rate ≥ 100 beats per minute before IABP insertion was the strongest predictor of 30-day mortality (hazard ratio = 5.69; 95% confidence interval, 1.49 to 21.78; p = 0.011). In ACS patients presenting with either cardiogenic shock, resuscitated, or patients who needed mechanical ventilation suffered from high mortality, despite the use of IABP. IABP appears to be safe and tended to be favorable in noncardiogenic shock ACS patients, particularly non-STE-ACS. A heart rate of ≥ 100 beats per minute prior to IABP insertion was the strongest predictor of 30-day mortality.