Senescent CD4+ T-Cell Phenotypes and Inflammatory Milieu in the Coronary and Systemic Circulation in ST-Elevation Myocardial Infarction: An Exploratory Study.

INTRODUCTION: In ST-elevation myocardial infarction (STEMI), inflammation is pivotal, with early senescent CD4+CD28null cells implicated in its pathogenesis. However, the functional phenotype of these cells within the coronary circulation remains unclear. METHODS: We examined CD4+ cell subpopulations in blood samples from the coronary sinus and vena cava of 24 STEMI patients and the cephalic vein of seven healthy controls. RESULTS: Our findings revealed reduced CD4+ cell counts in STEMI patients compared to controls (1,998, 1,275-3,268 vs. 4,278, 3,595-4,449), alongside an increased proportion of CD4+ cells lacking CD28 expression (20.1 vs. 6.1%). These CD4+CD28null cells in STEMI predominantly exhibited a Th1 phenotype (47.8% vs. 6.6%). Intriguingly, no significant differences were detected in CD4+CD28null cells between coronary sinus and vena cava, and cytokine levels in these compartments remained similar. CONCLUSION: CD4+CD28null cells are increased in STEMI, mainly polarized toward a Th1 phenotype, and distributed equally between the different vascular beds.

Selective embolization with autologous fat to treat massive bleeding secondary to percutaneous renal biopsy.

Bleeding following a percutaneous renal biopsy is a complication that can be life-threatening. Embolization of the bleeding artery is a procedure that can limit the damage; however, embolization devices can be costly or not immediately available. This is why we present the case of a 25-year-old man with a history of multiple thromboses who underwent a renal biopsy due to suspected systemic lupus erythematosus. Five days after the procedure, he developed hypovolemic shock. A CT scan was performed due to suspected hemorrhage and showed active bleeding at the renal biopsy site. Since embolization devices were not immediately available, selective embolization of the bleeding artery was successfully performed using autologous fat. It is known that embolization with coils is the most frequently used interventional procedure to stop bleeding secondary to renal biopsies. However, embolization with autologous fat is a proven technique to stop bleeding in coronary perforations. In this case, we adapted this technique to treat an actively bleeding renal artery secondary to a renal biopsy. Based on this case, we consider that this technique may be an alternative when coil embolization is not available.

Thrombocytopenia after transcatheter aortic valve implantation.

INTRODUCTION AND OBJECTIVES: Thrombocytopenia frequently occurs after transcatheter aortic valve implantation (TAVI) but its impact is poorly understood. We aimed to analyze the incidence, clinical impact, and predictors of acquired thrombocytopenia after TAVI. METHODS: This retrospective multicenter registry included 3913 patients undergoing TAVI with a baseline platelet count of ≥ 100 *109/L. Acquired thrombocytopenia was defined as a decrease in baseline platelet count of ≥ 50% (early nadir ≤ 3 days and late nadir ≥ 4 days) post-TAVI. The primary endpoint was 30-day all-cause mortality and secondary endpoints were procedural safety and 2-year all-cause mortality. RESULTS: The incidence of acquired thrombocytopenia was 14.8% (early nadir: 61.5%, late nadir: 38.5%). Thirty-day mortality occurred in 112 (3.0%) patients and was significantly higher in those with thrombocytopenia (8.5% vs 2.0%, adjusted OR, 2.3; 95%CI, 1.3-4.2). Procedural safety was lower and 2-year mortality was higher in patients with thrombocytopenia vs those without (52.1 vs 77.0%; P <.001, and 30.2% vs 16.8%; HR, 2.2, 95%IC, 1.3-2.7) and especially in those with late nadir thrombocytopenia (45.8% vs 54.5%; P=.056, and 38.6% vs 23.8%, HR, 2.1; 95%CI, 1.5-2.9). Independent predictors of thrombocytopenia comprised baseline and procedural factors such as body surface area, absence of diabetes, poorer renal function, peripheral vascular disease, nontransfemoral access, vascular complications, type of transcatheter heart valve, and earlier TAVI procedures. CONCLUSIONS: Acquired thrombocytopenia was common (15%) after TAVI and was associated with increased short- and mid-term mortality and decreased procedural safety. Moreover, late thrombocytopenia compared with early thrombocytopenia was associated with significantly worse clinical outcomes. Further investigations are needed to elucidate the etiologic mechanisms behind these findings.

Prevalence and prognostic implications of the no-reflux phenomenon in patients undergoing primary percutaneous coronary intervention at a university center in a middle-income country.

OBJECTIVE: To analyze the prevalence of no-reflow and the 30-day mortality in a university center in a middle-income country. METHOD: We analyzed 2463 patients who underwent primary PCI from January 2006 to December 2021. The outcome measure was 30-day mortality. RESULTS: Of a total of 2463 patients, no-reflow phenomenon was found in 413 (16.8%) patients, 30-day mortality was 16.7 vs. 4.29% (p < 0.001). Patients with no-reflow were older 60 (53-69.5) vs. 59 (51-66) (p = 0.001), with a higher delay in onset of symptom to emergency department arrival 270 vs. 247 min (p = 0.001). No-reflow patients also had had fewer previous myocardial infarction, 11.6 vs. 18.4 (p = 0.001) and a Killip class > 1, 37 vs. 26% (p < 0.001). No-reflow patients were more likely to have an anterior myocardial infarction (55.4 vs. 47.8%; p = 0.005) and initial TIMI flow 0 (76 vs. 68%; p < 0.001). CONCLUSION: No-reflow occurred in 16.8% of STEMI patients undergoing primary PCI and was more likely with older age, delayed presentation, anterior myocardial infarction and Killip class > 1. No-reflow was associated with a higher mortality at 30-day follow-up.

OBJETIVOS: Analizar la prevalencia de no reflujo y la mortalidad a 30 días en un centro universitario de un país de ingresos medios. MÉTODO: Analizamos 2,463 pacientes que se sometieron a ICP primaria desde enero de 2006 hasta diciembre de 2021. La medida de resultado fue la mortalidad a los 30 días. RESULTADOS: Del total de 2,463 pacientes, se encontró fenómeno de no reflujo en 413 (16.8%), la mortalidad a los 30 días fue del 16.7 vs. 4.29% (p < 0.001). Los pacientes sin reflujo tenían mayor edad 60 (53-69.5) vs. 59 (51-66) (p = 0.001), con mayor retraso del inicio de los síntomas a la llegada a urgencias, 270 vs. 247 min (p = 0.001). Los pacientes sin reflujo también tenían menos infarto de miocardio previo, 11.6 vs. 18.4 (p = 0.001), y una clase Killip > 1, 37 vs. 26% (p < 0.001). Los pacientes sin reflujo tenían más probabilidades de tener un infarto de miocardio anterior (55.4 vs. 47.8%; p = 0.005) y flujo TIMI inicial 0 (76 vs. 68%; p < 0.001). CONCLUSIÓN: Ocurrió ausencia de reflujo en el 16.8% de los pacientes con IAMCEST sometidos a ICP primaria y fue más probable con la edad avanzada, presentación tardía, infarto de miocardio anterior y clase Killip > 1. El no reflujo se asoció con una mayor mortalidad a los 30 días de seguimiento.

[Acute myocardial infarction patients without COVID-19 manifestations in the pandemic may have high thrombus burden]. / Pacientes con infarto agudo de miocardio sin manifestaciones de COVID-19 pueden tener alta carga de trombo.

Objective: The objective of the study is to identify clinical and angiographic characteristics of patients with ST-segment elevation myocardial infarction (STEMI) but without clinical manifestations of COVID-19 infection during the pandemic, compared with patients 1 year before the pandemic. Methods: Observational study that included 138 consecutive patients hospitalized with STEMI who underwent primary percutaneous coronary intervention (PCI) without COVID-19 infection during the 2020 pandemic. A group of 175 STEMI patients treated with PCI in the year before the pandemic served as the control group. Results: During the periods analyzed, compared with the control group, patients admitted during the pandemic without clinical manifestations of COVID-19 did not have significant differences in demographic characteristics, comorbidities, or delayed time and location of the acute myocardial infarction. Furthermore, there were no differences between the two groups concerning levels of CK-MB and NT-proBNP, or in inflammation markers and left ventricular ejection fraction. In patients without COVID-19 during the pandemic compared with control, we found a higher intracoronary thrombus burden (thrombus grade 5; 78.3% vs. 62.9%, respectively. p = 0.002). Accordingly, the use of glycoprotein IIB/IIIa inhibitors (37.7% vs. 26.3%, p = 0.03) was higher in these patients. Conclusions: This study demonstrates an increased thrombus burden in STEMI patients without clinical manifestation of COVID-19 during the pandemic compared with the same time period in the previous year.

Objetivo: Identificar las características clínicas y angiográficas de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) sin manifestaciones clínicas de COVID-19 durante la pandemia y compararlos con los pacientes en el año previo. Métodos: Estudio observacional que incluyó 138 pacientes consecutivos que fueron hospitalizados por IAMCEST y que fueron tratados con angioplastía primaria (ACTP) sin manifestaciones clínicas de COVID-19 durante la pandemia de 2020. Se seleccionó a un grupo control de 175 pacientes con IAMCEST tratados con ACTP en el año previo a la pandemia. Resultados: Los pacientes atendidos durante la pandemia no tuvieron diferencias significativas en cuanto a las características clínicas, demográficas, comorbilidades, tiempo de retraso y localización del infarto. Además, no hubo diferencias entre ambos grupos en los niveles de CK-MB, NT-proBNP, marcadores de inflamación ni en la fracción de eyección del ventrículo izquierdo. En los pacientes sin COVID-19 tratados durante la pandemia encontramos mayor carga trombótica intracoronaria (trombo grado 5; 78.3% vs. 62.9%, respectivamente. p = 0.002). De igual manera, el uso de inhibidores de la glucoproteina IIB/IIIa (37.7% vs. 26.3%, p = 0.03) fue mayor. Conclusiones: Este studio demostró un aumento en la carga trombótica en los pacientes con IAMCEST sin manifestaciones clínicas de COVID-19 durante la pandemia al compararlos con los pacientes tratados por la misma patología en el año previo.

Left atrial veno-arterial extracorporeal membrane oxygenation in post-myocardial infarction ventricular septal defect with cardiogenic shock: a case report.

Background: Ventricular septal defect (VSD) complicating acute myocardial infarction (MI) represents a life-threatening condition and has a mortality of >90% if left untreated. Case summary: A 53-year-old man with a prior medical history of diabetes and hypertension presented with cardiogenic shock secondary to VSD as a mechanical complication of non-reperfused inferior MI. Discussion: The choice of mechanical support can be difficult in this type of patient. Given the risk of an increased shunt because of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and the increase in left ventricle (LV) afterload, several measures were taken to plan the best ECMO configuration. Given the absence of any real improvement in the LV and an elevated residual ratio between pulmonary and systemic flow (Qp/Qs), the final decision was to switch to left atrial VA-ECMO (LAVA-ECMO). The use of LAVA-ECMO improved the patient's haemodynamics and allowed his condition to stabilize; LAVA-ECMO is feasible and may be effective as a mechanical circulatory support (MCS) strategy for patients in cardiogenic shock due to VSD as a mechanical complication of acute MI.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach.

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Left circumflex artery injury occurring during mitral valve surgery treated successfully with percutaneous intervention in a high surgical and bleeding risk patient.

Perioperative myocardial infarction is a complication of cardiac surgery, and the cause can be multifactorial. Injury of the left circumflex coronary artery has been described, particularly after mitral valve replacement. We present the case of a 72-year-old woman who underwent mitral valve replacement but developed a lesion in the proximal circumflex coronary artery related to partial mechanical kinking caused by a suture. The therapeutic options are surgical or percutaneous. In this patient, the percutaneous strategy was successful. Learning objective: • Percutaneous coronary intervention is an option in cases involving kinking of the left circumflex coronary artery after mitral valve replacement.• If unable to cross the lesion with a workhorse guide wire, one alternative is to use wires with good support properties and avoid very high tip loads to reduce the risk of perforation.In patients at high risk of bleeding, use of a drug-eluting stent and short-duration dual antiplatelet therapy is recommended.

Dynamic Invasive Hemodynamic Congestion Profile Impacts Acute Myocardial Infarction Complicated by Cardiogenic Shock Outcomes: A Real-World Single-Center Study.

BACKGROUND: Cardiogenic shock (CS) commonly complicates the management of acute myocardial infarction (AMI), and it results in high mortality rates. Pulmonary artery catheter (PAC) monitoring can be valuable for personalizing critical-care interventions. We hypothesized that patients with AMI-CS experiencing persistent congestion measures during the first 24 hours of the PAC installment would exhibit worse in-hospital survival rates. METHODS AND RESULTS: We studied 295 patients with AMI-CS between January 2006 and December 2021. The first 24-hour PAC-derived hemodynamic measures were divided by the congestion profiling and the proposed 2022 Cardiovascular Angiography and Interventions (SCAI) classification. Biventricular congestion was the most common profile and was associated with the highest patient mortality rates at all time points (mean 56.6%). A persistent congestive profile was associated with increased mortality rates (hazard ratio [HR] = 1.85; P = 0.002) compared with patients who achieved decongestive profiles. Patients with SCAI stages D/E had higher levels of right atrial pressure (RAP): 14-15 mmHg) and pulmonary capillary wedge pressure (PCWP): 18-20 mmHg) compared with stage C (RAP, 10-11 mmHg, mean difference 3-5 mmHg; P < 0.001; PCWP 14-17 mmHg; mean difference 1.56-4 mmHg; P = 0.011). In SCAI stages D/E, the pulmonary artery pulsatility index (0.8-1.19) was lower than in those with grade C (1.29-1.63; mean difference 0.21-0.73; P < 0.001). CONCLUSIONS: Continuous congestion profiling using the SCAI classification matched the grade of hemodynamic severity and the increased risk of in-hospital death. Early decongestion appears to be an important prognostic and therapeutic goal in patients with AMI-CS and warrants further study.

Aortic Perforation and Ascending Dissection Due to Intra-Aortic Balloon Counterpulsation Implantation in Cardiac Surgery.

The intra-aortic balloon pump continues to be a useful ventricular assist device in cardiac surgery. Complications are estimated to be 7% to 40%, significantly high to catastrophic. We describe an aortic injury associated with the use of the device and an interdisciplinary management for the diagnostic and therapeutic approach. (Level of Difficulty: Intermediate.).

Application of the SCAI classification to admission of patients with cardiogenic shock: Analysis of a tertiary care center in a middle-income country.

AIMS: The Society of Cardiovascular Angiography and Interventions (SCAI) shock stages have been applied and validated in high-income countries with access to advanced therapies. We applied the SCAI scheme at the time of admission in order to improve the risk stratification for 30-day mortality in a retrospective cohort of patients with STEMI in a middle-income country hospital at admission. METHODS: This is a retrospective cohort study, we analyzed 7,143 ST-segment elevation myocardial infarction (STEMI) patients. At admission, patients were stratified by the SCAI shock stages. Multivariate analysis was used to assess the association between SCAI shock stages to 30-day mortality. RESULTS: The distribution of the patients across SCAI shock stages was 82.2%, 9.3%, 1.2%, 1.5%, and 0.8% to A, B, C, D, and E, respectively. Patients with SCAI stages C, D, and E were more likely to have high-risk features. There was a stepwise significant increase in unadjusted 30-day mortality across the SCAI shock stages (6.3%, 8.4%, 62.4%, 75.2% and 88.3% for A, B, C, D and E, respectively; P < 0.0001, C-statistic, 0.64). A trend toward a lower 30-day survival probability was observed in the patients with advanced CS (30.3, 15.4%, and 8.3%, SCAI shock stages C, D, and E, respectively, Log-rank P-value <0.0001). After multivariable adjustment, SCAI shock stages C, D, and E were independently associated with an increased risk of 30-day death (hazard ratio 1.42 [P = 0.02], 2.30 [P<0.0001], and 3.44 [P<0.0001], respectively). CONCLUSION: The SCAI shock stages applied in patients con STEMI at the time of admission, is a useful tool for risk stratification in patients across the full spectrum of CS and is a predictor of 30-day mortality.

Cardiothoracic surgery and peripheral endovascular intervention in cardiovascular damage from a cohort of orphan rheumatological diseases-epidemiological and survival analysis.

Background: Aortic diseases in some orphan rheumatological diseases require medical, surgical or peripheral endovascular intervention because they can be catastrophic. Objectives: to analyze the main clinical and epidemiological characteristics of patients with Takayasu arteritis (TA), Marfan syndrome (MS) and similar conditions that were treated with cardiothoracic surgery and peripheral endovascular intervention. Methods: Retrospective and descriptive cohort study that included patients of any age and gender with TA (as per the criteria of the American College of Rheumatology and EULAR/PRINTO), MS (according to Ghent criteria), and similar conditions who underwent cardiothoracic surgery or peripheral endovascular intervention. Data were collected from electronic charts. Results: A total of 77 patients with TA and 135 patients with MS and similar conditions were included. The frequency of surgical or interventional requirements in patients with TA and MS/similar conditions was 77/364 (21.2%) and 135/300 (45%), respectively; such patients were followed for a median of 6 [2-12] and 3.29 (0.42-6.62) years, with (maximum follow-up range of 47 and 21.37 years, respectively). Aneurysms were present in 11 (14.3%) and 66 (48.9%) in patients with TA and MS/similar conditions, respectively. Aortic, mitral and tricuspid valve damage occurred in 8 (10.4%) patients, 4 (5.2%) patients and 1 (1.3%) patient with TA, respectively; corresponding frequencies in patients with MS/similar conditions were 98 (72.6%), 50 (37.0%) and 20 (14.8%). We identified that 20% of patients with TA died after 5.08 years (95% CI: 0.23-25.42 years) and 20 % of the patients with MS and other similar conditions died after 7.52 years (95% CI: 1.10-9.02 years). Conclusions: The frequency of surgical intervention was low in this study. Long-term prognosis is good if surgery is performed in a timely manner. Epidemiological studies provide relevant information for public health decisions related to the management of orphan rheumatological diseases.

Prevention of Radial Artery Occlusion of 3 Hemostatic Methods in Transradial Intervention for Coronary Angiography.

OBJECTIVES: The main objective of this study was to compare the efficacy of 3 hemostatic methods for the prevention of early radial artery occlusion (RAO): standard patent hemostasis, patent hemostasis with ulnar compression or the ulnar artery transient compression facilitating radial artery patent hemostasis (ULTRA) method, and facilitated hemostasis with a hemostatic disc. BACKGROUND: There are no prospective randomized studies that compare early RAO rates with the 3 most used nonocclusive hemostatic methods. METHODS: This was a prospective, longitudinal, comparative, and randomized study. The final population analyzed was 1,469, and they were randomized into 3 groups: 491 patients in group 1 with standard patent hemostasis, 490 patients in group 2 with the ULTRA method, and 488 patients in group 3 with facilitated hemostasis with a hemostatic disc. RESULTS: The RAO rate at 24 hours of the total population analyzed was 4.6%. By hemostasis groups, it was 3.6% for patent hemostasis, 5.5% for the ULTRA method, and 4.7% for facilitated hemostasis with a hemostatic disc, with no statistical difference among the 3 groups (P = 0.387). At 30 days, the overall rate of RAO was 1.8%, and by groups, it was 1.4% for the patent hemostasis group, 1.8% for the ULTRA method group, and 2.2% for the facilitated hemostasis with a hemostatic disc group, respectively (P = 0.185). CONCLUSIONS: The rates of RAO at 24 hours evaluated by plethysmography oximetry and confirmed by ultrasound among 3 current radial hemostasis methods (ie, patent hemostasis, the ULTRA method, and facilitated hemostasis with a hemostatic disc) are not different.

Bioprosthetic valve failure. Comparative trial of two balloon-expandable transcatheter heart valve systems in intermediate-risk patients: a propensity score analysis.

BACKGROUND: The comparative mid and long-term durability, including the rates of bioprosthetic valve failure (BVF) of the Sapien XT® and Sapien 3® transcatheter heart valve (THV) in patients with intermediate surgical risk has not been reported. METHODS: Consecutive intermediate-risk patients with severe aortic stenosis from the Mexican registry of transcatheter aortic valve replacement (TAVR) with Sapien® THVs were included. The primary endpoint was to compare the BVF rate between THVs at 2 years of follow-up. Secondary endpoints were comparisons of the composite of global mortality, cardiovascular mortality, and neurological events at 30 d and 24 months of follow-up. RESULTS: During 2014-2019, 115 (60 Sapien XT® and 55 Sapien 3®) patients met the inclusion criteria in five medical centres. The mean age was 77.3 ± 8.4 years. The average Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was 5.6 ± 2.9. There was no statistically significant difference between the groups in BVF rate. At 30 d, overall, cardiovascular and non-cardiovascular mortality was 4.3%, 2.6%, and 1.7%, respectively. Neurological events rate was 1.73%. The mean long-term follow-up was 25.3 ± 14.2 months with an overall mortality of 9.56% but lower for the Sapien 3® group (15% vs. 3.6%, p=.037). The only independent predictor of composite mortality and neurological events that occurred in the long term was using a Sapien XT® [OR 1.6, CI 95%, 1.0-24.9; p=.049]. CONCLUSIONS: The BVF rate at 25 months of follow-up was similar with the XT and S3 systems. During this follow-up period, the major composite events of death from any cause and neurological events were significantly lower with the S3 system.

Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study.

Background: Latin America has limited information about the full spectrum cardiogenic shock (CS) and its hospital outcome. This study sought to examine the temporal trends, clinical features and outcomes of patients with CS in a coronary care unit of single Mexican institution. Methods: This was a retrospective study of consecutive patients hospitalized with CS in a Mexican teaching hospital between 2006-2019. Patients were classified according to the presence or absence of acute myocardial infarction (AMI). Results: Of 22,747 admissions, 833 (3.7%) exhibited CS. Among patients with AMI (n = 12,438), 5% had AMI-CS, and in patients without AMI (n = 10,309), 2.3% developed CS (non-AMI-CS). Their median age was 63 years and 70.5% were men. Cardiovascular risk factors were more frequent among the AMI-CS group, whereas a history of heart failure was greater in non-AMI-CS patients (70.1%). In AMI-CS patients, the median delay time was 17.2 hours from the onset of AMI symptoms to hospital admission. Overall, the median left ventricular ejection fraction (LVEF) was 30%. Patients with CS at admission showed end-organ dysfunction, evidenced by lactic acidosis, renal impairment, and elevated liver transaminases. Of the 620 AMI-CS patients, the main cause was left ventricular dysfunction in 71.3%, mechanical complications in 15.2% and right ventricular infarction in 13.5%. Among the 213 non-AMI-CS patients, valvular heart disease (49.3%) and cardiomyopathies (42.3%) were the most frequent etiologies. In-hospital all-cause mortality rates were 69.7% and 72.3% in the AMI-CS and non-AMI-CS groups, respectively. Among AMI-CS patients, renal dysfunction, diabetes, older age, depressed LVEF, absence of revascularization and the use of mechanical ventilation were independent predictors of in-hospital mortality. However, in the non-AMI-CS group, only low LVEF and high lactate levels proved significant. Conclusions: This study demonstrates differences in the epidemiology of CS compared to high-income countries; the high mortality reflects critically ill patients and the lack of contemporary effective therapies in the population studied.

Pharmacoinvasive Strategy vs Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Study in Mexico City.

BACKGROUND: A low proportion of patients with ST-elevation myocardial infarction (STEMI) in low- to middle-income countries receive reperfusion therapy. Although primary percutaneous coronary intervention (PCI) is the method of choice, a pharmacoinvasive strategy (PIs) is reasonable when primary PCI cannot be delivered on a timely basis. The aim of our study was to assess the efficacy and safety of a PIs compared with primary PCI in a real-world setting. METHODS: This was a prospective registry that included patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary composite end point was the occurrence of cardiovascular death, cardiogenic shock, recurrent myocardial infarction, or congestive heart failure at 30 days according to the reperfusion strategy used. The key safety end point was major bleeding (Bleeding Academic Research Consortium [BARC] score 3-5) at 30 days. RESULTS: We included 579 patients with STEMI, 49.7% underwent primary PCI and 50.2% received PIs. Those who received a PIs approach were more likely to present with Killip class > 1 and to have a history of diabetes but were less likely to have a previous cardiovascular disease diagnosis. No statistically significant difference was shown in the primary composite end point according to reperfusion strategy (hazard ratio for PIs, 0.76; 95% confidence interval, 0.48-1.21; P = 0.24). Major bleeding was not different among groups (hazard ratio for PIs, 0.92; 95% confidence interval, 0.45-1.86; P = 0.81). Two patients in the PIs group (0.6%) and no patients in the PCI group had intracranial bleeding (P = 0.15). CONCLUSIONS: In this prospective real-world registry, major cardiovascular outcomes and bleeding were not different among patients who underwent a PIs or primary PCI. The study suggests that a PIs is an effective and safe option for patients with STEMI when access to primary PCI is limited.

CONTEXTE: Une faible proportion des patients qui subissent un infarctus du myocarde avec élévation du segment ST (STEMI) dans les pays à revenus faibles/intermédiaires reçoivent un traitement de reperfusion. Même si l'intervention coronarienne percutanée (ICP) primaire constitue la méthode de prédilection, une stratégie pharmaco-invasive  représente une option raisonnable lorsque l'ICP primaire ne peut être réalisée dans un délai acceptable. Cette étude visait à évaluer l'efficacité et l'innocuité d'une stratégie pharmaco-invasive comparativement à une ICP primaire dans la pratique courante. MÉTHODOLOGIE: Cette étude consistait en une étude de registre prospective et regroupait des patients présentant un STEMI et ayant subi une reperfusion pendant les 12 heures suivant l'apparition des symptômes. Le principal critère d'évaluation regroupé correspondait à l'occurrence du décès cardiovasculaire, du choc cardiogénique, d'une récidive de l'infarctus du myocarde ou d'une insuffisance cardiaque congestive dans les 30 jours suivants, selon la stratégie de reperfusion utilisée. Le principal critère d'évaluation de l'innocuité était les hémorragies majeures (score de 3 à 5 selon le Bleeding Academic Research Consortium [BARC]) à 30 jours. RÉSULTATS: L'étude regroupait 579 patients présentant un STEMI, dont 49,7 % avaient subi une ICP primaire et 50,2 % avaient reçu une stratégie pharmaco-invasive. Les patients ayant reçu une stratégie pharmaco-invasive étaient plus susceptibles de présenter une classe de Killip > 1 et des antécédents de diabète, mais étaient moins susceptibles d'avoir déjà reçu un diagnostic de maladie cardiovasculaire. Aucune différence significative sur le plan statistique n'a été observée pour ce qui est du principal critère d'évaluation regroupé selon la stratégie de reperfusion (rapport des risques instantanés [RRI] de la stratégie pharmaco-invasive : 0,76; intervalle de confiance [IC] à 95 % : 0,48-1,21; p = 0,24). Aucune différence n'a été observée entre les groupes quant aux hémorragies majeures (RRI de la stratégie pharmaco-invasive : 0,92; IC à 95 % : 0,45-1,86; p = 0,81). Deux patients du groupe ayant reçu une stratégie pharmaco-invasive (0,6 %) ont présenté une hémorragie intracrânienne, comparativement à aucun patient du groupe ayant subi une ICP (p = 0,15). CONCLUSIONS: Selon cette étude de registre prospective en pratique courante, les résultats concernant les hémorragies et les événements cardiovasculaires majeurs n'ont pas été différents entre les patients ayant subi une ICP primaire et ceux ayant reçu une stratégie pharmaco-invasive. L'étude suggère que la stratégie pharmaco-invasive constitue une option sûre et efficace pour les patients qui présentent un STEMI, lorsque l'accès à une ICP primaire est limité.