Coronary Embolism Among Patients With ST-Segment-Elevation Myocardial Infarction and Atrial Fibrillation: An Underrecognized But Deadly Association.

BACKGROUND: The prevalence and impact of coronary emboli (CE) in patients with ST-segment-elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI. METHODS AND RESULTS: We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P<0.05), more likely to be female (43% versus 22%, P<0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P<0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45-day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P<0.05 and group A versus group B: 20% versus 8%, P=not significant); this trend persisted at 2-year follow-up (group A versus group C: 24% versus 6%; P<0.05 and group A versus group B: 24% versus 17%, P=not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45-day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P<0.05). CONCLUSIONS: In patients presenting with STEMI and AF, CE was associated with excess early mortality. REGISTRATION: URL: clinicaltrials.gov. Identifier: NCT05679843.

Outcomes after acute coronary syndrome in patients with inflammatory bowel disease.

BACKGROUND: Patients with chronic inflammatory conditions are at an increased risk of developing atherothrombotic events. We aimed to assess the 1-year prognosis after myocardial infarction (MI) in patients with inflammatory bowel disease (IBD). METHODS: From the PMSI (Program de Medicalisation des Systèmes d'informatique) database, 246 out of 39,835 consecutive MI patients, hospitalized between 2012 and 2017, were diagnosed with IBD and followed up for 1 year after discharge. A matched cohort was built matching each MI patient with IBD to patient without IBD using age and sex (n = 1,470, matching ratio 1:5). RESULTS: Compared with MI patients without IBD, MI patients with IBD were younger (aged 69 vs. 70.8 years, p = 0.04) with a higher rate of increased body mass index (BMI) (21.5% vs 15%, p = 0.004), previously diagnosed ischemic cardiopathy (18.3% vs 12.6%, p < 0.0008) and chronic renal disease (8.9% vs 5.6%, p = 0.02). In our age- and sex-matched cohort, we found that all-cause mortality (9% vs 8.3, p = 0.729), stroke (0.8% vs 0.6%, p = 0.656) and hospitalization resulting from heart failure (3ool, .3% vs 3.5%, p = 0.846) did not significantly differ between the IBD and non-IBD groups within the first year after initial admission whereas the risk of recurrent MI was increased by 50% (2.9% vs 1.9%, p = 0.33) in the IBD group without reaching statistical significance. Moreover, a significant increase in the blood transfusion rate at the 1-year follow-up was observed in MI patients with IBD compared with MI patients without IBD (15.1% vs 9.4%, p < 0.001). CONCLUSION: Our findings suggest that both residual MI risk and bleeding events should be carefully monitored in MI patients diagnosed with chronic inflammation such as that observed in IBD.

Changes in characteristics and management among patients with ST-elevation myocardial infarction due to COVID-19 infection.

OBJECTIVES: To assess changes in characteristics and management among ST-elevation myocardial infarction (STEMI) patients with coronavirus disease (COVID-19) who underwent primary percutaneous coronary intervention. METHODS: Our prospective, monocentric study enrolled all STEMI patients who underwent PPCI during the COVID-19 outbreak (n = 83). This cohort was first compared with a previous cohort of STEMI patients (2008-2017, n = 1,552 patients) and was then dichotomized into a non-COVID-19 group (n = 72) and COVID-19 group (n = 11). RESULTS: In comparison with the pre-outbreak period, patients during the outbreak period were older (59.6 ± 12.9 vs. 62.6 ± 12.2, p = .03) with a delayed seek to care (mean delay first symptoms-balloon 3.8 ± 3 vs. .7.4 ± 7.7, p < .001) resulting in a two-fold higher in-hospital mortality (non COVID-19 4.3% vs. COVID-19 8.4%, p = .07). Among the 83 STEMI patients admitted during the outbreak period, 11 patients were infected by COVID-19. Higher biological markers of inflammation (C-reactive protein: 28 ± 39 vs. 98 ± 97 mg/L, p = .04), of fibrinolysis (D-dimer: 804 ± 1,500 vs. 3,128 ± 2,458 µg/L, p = .02), and antiphospholipid antibodies in four cases were observed in the COVID-19 group. In this group, angiographic data also differed: a thrombotic myocardial infarction nonatherosclerotic coronary occlusion (MINOCA) was observed in 11 cases (1.4% vs. 54.5%, p < .001) and associated with higher post-procedure distal embolization (30.6% vs. 72.7%, p = .007). The in hospital mortality was significantly higher in the COVID-19 group (5.6% vs. 27.3%, p = .016). CONCLUSION: The COVID-19 outbreak implies deep changes in the etiopathogenesis and therapeutic management of STEMI patients with COVID-19. The impact on early and long-term outcomes of systemic inflammation and hypercoagulability in this specific population is warranted.

Impact of Fractional Flow Reserve Derived From Coronary Computed Tomography Angiography on Heart Team Treatment Decision-Making in Patients With Multivessel Coronary Artery Disease: Insights From the SYNTAX III REVOLUTION Trial.

BACKGROUND: Fractional flow reserve (FFR) is a reliable tool for the functional assessment of coronary stenoses. FFR computed tomography (CT) derived (FFRCT) has shown to be accurate, but its clinical usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the impact of FFRCT on heart team's treatment decision-making and selection of vessels for revascularization in patients with 3-vessel coronary artery disease. METHODS: The trial was an international, multicenter study randomizing 2 heart teams to make a treatment decision between percutaneous coronary interventions and coronary artery bypass grafting using either coronary computed tomography angiography or conventional angiography. The heart teams received the FFRCT and had to make a treatment decision and planning integrating the functional component of the stenoses. Each heart team calculated the anatomic SYNTAX score, the noninvasive functional SYNTAX score and subsequently integrated the clinical information to compute the SYNTAX score III providing a treatment recommendation, that is, coronary artery bypass grafting, percutaneous coronary intervention, or equipoise coronary artery bypass grafting-percutaneous coronary intervention. The primary objective was to determine the proportion of patients in whom FFRCT changed the treatment decision and planning. RESULTS: Overall, 223 patients were included. Coronary computed tomography angiography assessment was feasible in 99% of the patients and FFRCT analysis in 88%. FFRCT was available for 1030 lesions (mean FFRCT value 0.64±13). A treatment recommendation of coronary artery bypass grafting was made in 24% of the patients with coronary computed tomography angiography with FFRCT. The addition of FFRCT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as reference, FFRCT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile. CONCLUSIONS: In patients with 3-vessel coronary artery disease, a noninvasive physiology assessment using FFRCT changed heart team's treatment decision-making and procedural planning in one-fifth of the patients. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02813473.

Primary percutaneous coronary intervention in ST-elevation myocardial infarction with an ectatic infarct-related artery.

OBJECTIVE: The aim of this study was to describe the procedural characteristics, myocardial perfusion, and long-term outcomes in ST-elevation myocardial infarction patients with an ectatic infarct-related artery (IRA). PATIENTS AND METHODS: The retrospective analysis included 1270 consecutive ST-elevation myocardial infarction patients treated by primary percutaneous coronary intervention who were categorized according to the coronary anatomy of the IRA as follows: ectatic group (n=91) and control group (n=1179). RESULTS: Compared with the control group, patients in the ectatic group experienced lower Thombolysis in myocardial infarction grade 3 flow rate after percutaneous coronary intervention (64.8 vs. 88.2%: ectatic group vs. nonectatic group, P<0.001) and more frequent distal embolization (44.4 vs. 11.1%, P<0.001). ECG ST resolution was significantly lower in the ectatic group (P<0.001). Paradoxically, the left ventricular ejection fraction values at discharge were significantly higher in the ectatic group (P=0.032) and the infarct size assessed within 6-12 months after discharge tended to be smaller (P=0.06). The 30-day mortality rate was not significantly different between the two groups (3.3 vs. 5.0%, P=0.378) as well as Kaplan-Meier analysis for long-term overall survival in both groups (P=0.8). CONCLUSION: Patients with ectatic IRA were characterized by discrepancies between high angiographic thrombus burden in a larger vessel and impact on left ventricular function that may influence their long-term survival.

The Simulation Training in Coronary Angiography and Its Impact on Real Life Conduct in the Catheterization Laboratory.

Our study aimed to evaluate the effectiveness of mentored simulation training (ST) in coronary angiography and to assess the transferability of acquired skills from virtual reality to the real world. Twenty cardiology residents were randomized to ST or control before performing real-life cases in the catheterization laboratory. The control group underwent secondary ST and reperformed real-life cases in the catheterization laboratory. Skill metrics were compared between the ST and the control group, and within the control group between before and after ST. In real-life cases, the procedure time was shorter (p = 0.002), the radiation dose lower (p = 0.001), and the global procedure skill score was higher (p = 0.0001) in the ST group as compared with the control (before ST) group. During virtual ST procedural time (p <0.001), fluoroscopic time (p <0.001), training contrast amount (p <0.001), and global training score (p <0.001) significantly decreased. In the control group, all monitoring procedure parameters were significantly improved after ST, as well as, the global procedure flow score (p <0.0001). In conclusion, simulator-based training in coronary angiography improved operator skills compared with traditional in catheterization laboratory mentor-based training. ST should be incorporated in the curriculum of the interventionalist to improve learning in coronary angiography.

Myocardial reperfusion for acute myocardial infarction under an optimized antithrombotic medication: What can you expect in daily practice?

AIMS: To assess both epicardiac macrovascular as well as microvascular and tissue reperfusion following different intravenous preadmission antithrombotic strategies prior primary PCI in STEMI patients. METHODS AND RESULTS: Consecutive STEMI patients (n = 488) undergoing pPCI received prehospitally either bivalirudin (n = 179), bivalirudin and periprocedural GPIIb/IIIa inhibitors (GPI) (n = 109), heparin (n = 99) or heparin and periprocedural GPI (n = 101). Epicardial perfusion and microvascular perfusion were assessed by angiography (TIMI flow rate and corrected TIMI frame count [cTFC]) and by ECG (ST resolution [STR]). TIMI 3 flow was restored at the end of the procedure in 85.2% of the cases; cTFC of ≤23 was obtained in 37.2% of cases and STR >70% in 42.5% of the cases. The rates of STR >70% and cTFC ≤23 were not different between the three groups. Multivariate analysis did not identify a predictive antithrombotic treatment to obtain either post-procedural TIMI 3 flow rate or a STR rate >70%. TIMI 3 flow before procedure and delay first symptoms-balloon <6 h represented a positive predictive value of STR rate >70% and the LAD as infarct related artery a negative predictive value of STR rate of >70%. CONCLUSION: The process of myocardial reperfusion by pPCI continues to be improved with earlier reperfusion but an optimal tissular reperfusion was present in only half of the cases.

Coronary Embolism Among ST-Segment-Elevation Myocardial Infarction Patients: Mechanisms and Management.

BACKGROUND: Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of ST-segment-elevation myocardial infarction. The objective was to describe clinical characteristics and long-term outcomes and to identify risks factors of CE in a large consecutive series of ST-segment-elevation myocardial infarction patients. METHODS AND RESULTS: We studied 1232 consecutive patients who presented with de novo ST-segment-elevation myocardial infarction. CE was diagnosed based on criteria encompassing clinical, angiographic, and diagnostic imaging findings. A total of 53 patients were identified in the CE group including 12 (22.6%) patients with multisites CE and 9 patients with other extracoronary localization. Compared with the non-CE group, age and coronary risks factors were not significantly different in the CE group except for smoking (P=0.03) and body mass index (P<0.001). Interventional coronary procedures were characterized by a higher use of glycoprotein IIb/IIIa inhibitors (P<0.001) and lower use of angioplasty (P<0.001) in the CE group. The most frequent underlying cardiac diseases were atrial fibrillation (n=15, 28.3%) followed by dilated cardiomyopathy (n=5), endocarditis (n=4), and intracardiac tumor (n=3), whereas among systemic diseases, malignancy (n=8) and systemic autoimmune disease or antiphospholipid syndrome (n=4) were present. No etiopathological mechanisms could be identified in 14 patients (26.4%). Coronary embolism was associated with a higher risk of death (crude hazard ratio, 4.87; 95% confidence interval, 2.52-9.39; P<0.0001). CONCLUSIONS: Etiopathogenesis of ST-segment-elevation myocardial infarction secondary to CE is diverse ranging from cardiac to systemic disease, and patient long-term survival is worse than expected according to the baseline cardiovascular risk.