Unfolding the reality of the smoking paradox in a South Asian cohort of patients presenting with ST-elevation acute coronary syndrome undergoing primary percutaneous coronary intervention.

Objectives: Smoking is a potent risk factor for coronary artery disease, but there is controversy about its protective nature in terms of prognosis in ST-elevation acute coronary syndrome patients undergoing primary percutaneous coronary intervention. So, the main objective of this study is to unfold this controversy in a South Asian population in terms of clinical angiographic parameters and its in-hospital outcomes. Methods: In this study, we included 1756 consecutive patients diagnosed with ST-elevation acute coronary syndrome undergoing primary percutaneous coronary intervention. Patients were classified into smokers and non-smokers, and the in-hospital mortality rate was compared. Multivariable logistic regression analysis was performed to evaluate the paradoxical role of smoking. Results: Smokers were younger (53.78 ± 11.16 years vs 56.43 ± 11.17 years; p < 0.001) and more frequently men (98.7% vs 69.9%; p < 0.001) and had less diabetes (19.6% vs 44.8%; p < 0.001) and hypertension (38.5% vs 64.9%; p < 0.001). Smokers presented less frequently in Killip III (5.6% vs 8.1%; p < 0.001) and Killip IV (2.5% vs 4.8%; p < 0.001). Smokers mostly had single vessel disease (41.7% vs 34.4%; p = 0.013), whereas non-smokers had the multi-vessel disease and frequently presented with total occlusion of the culprit vessel (64.6% vs 58.8%; p = 0.040). Smokers have significantly lesser mortality (1.8% vs 4.3%; p = 0.009) compared to non-smokers with an odds ratio of 0.41 (95% confidence interval (CI): 0.21-0.82, p = 0.011); however, adjusted odds ratio on multivariable analysis was 0.67 (95% CI: 0.31-1.41, p = 0.290). Conclusions: The paradoxical protective role of smoking is the confounding effect of mainly younger age, less coronary artery disease burden, lower prevalence of diabetes and hypertension, and lower Killip III/IV at presentation.

Age and gender-based categorization of very premature, premature, and non-premature acute myocardial infarction: A comparison of clinical and angiographic profile and in-hospital outcomes.

BACKGROUND: In this study, we aimed to assess and compare the distribution of demographic and clinical characteristics and composite adverse clinical outcomes after primary percutaneous coronary intervention (PCI) among "very premature", "premature", and "non-premature" patients with "ST-segment elevation acute coronary syndrome (STE-ACS)" presented at a tertiary care center. METHODS: We included consecutive patients diagnosed with STE-ACS undergoing primary PCI. The "very premature" was defined as ≤40 years for males and ≤ 45 years for females, "premature" as <55 years for males and < 65 years for females, and "non-premature" as ≥55 years for males and ≥ 65 years for females. Clinical characteristics, angiographic patterns, and hospital course were compared among the three groups. RESULTS: In a sample of 4686 patients, 78.8%(3691) were male, and the average age was 55.6 ± 11 years. In total, 12%(561) were categorized as very premature, 38.3%(1797) as premature, and 49.7%(2328) as non-premature. The distribution of clinical characteristics in very premature, premature, and non-premature groups were as follows; hypertension in 44.6% vs. 53.5% vs. 54.9%; p < 0.001, diabetes in 30.3% vs. 36.8% vs. 35.5%; p = 0.018, smoking in 29.6% vs. 23.3% vs. 26.3%; p = 0.005, obesity in 19.4% vs. 18.4% vs. 15.3%; p = 0.008, single vessel diseases in 58.8% vs. 37.8% vs. 28.8%; p < 0.001, and composite adverse clinical outcomes in 14.1% vs. 16.7% vs. 21.8%; p < 0.001, respectively. CONCLUSION: In conclusion, we have a substantial burden of premature STE-ACS. Very premature STE-ACS was found to be associated with a better prognosis, but a substantial burden of composite adverse clinical outcomes was also observed.

Predilation Ballooning in High Thrombus Laden STEMIs: An Independent Predictor of Slow Flow/No-Reflow in Patients Undergoing Emergent Percutaneous Coronary Revascularization.

Background: Distal embolization due to microthrombus fragments formed during predilation ballooning is considered one of the possible mechanisms of slow flow/no-reflow (SF/NR). Therefore, this study aimed to compare the incidence of intraprocedure SF/NR during the primary percutaneous coronary intervention (PCI) in patients with high thrombus burden (≥4 grade) with and without predilation ballooning for culprit lesion preparation. Methodology. This prospective descriptive cross-sectional study included patients with a high thrombus burden (≥4 grades) who underwent primary PCI. Propensity-matched cohorts of patients with and without predilation ballooning in a 1 : 1 ratio were compared for the incidence of intraprocedure SF/NR. Results: A total of 765 patients with high thrombus burden undergoing primary PCI were included in this study. The mean age was 55.75 ± 11.54 years, and 78.6% (601) were males. Predilation ballooning was conducted in 346 (45.2%) patients. The incidence of intraprocedure SF/NR was significantly higher (41.3% vs. 27.4%; p < 0.001) in patients with predilation ballooning than in those without preballooning, respectively. The incidence of intraprocedure SF/NR also remained significantly higher for the predilation ballooning cohort with an incidence rate of 41.3% as against 30.1% (p=0.002) for the propensity-matched cohort of patients without predilation ballooning with a relative risk of 1.64 (95% CI: 1.20 to 2.24). Moreover, the in-hospital mortality rate remained higher but insignificant, among patients with and without predilation ballooning (8.1% vs. 4.9%; p=0.090). Conclusion: In conclusion, predilation ballooning can be associated with an increased risk of incidence of intraprocedure SF/NR during primary PCI in patients with high thrombus burden.

Assessing in-hospital mortality and predictors in Patients with contrast-induced nephropathy Following primary percutaneous coronary Intervention.

BACKGROUND: The contrast-induced nephropathy (CIN) is a common complication of primary percutaneous coronary intervention (PCI) it has been reported to be associated with an increased risk of mortality. The study reported the in-hospital mortality among patients who developed CIN after primary PCI. METHODS: This descriptive cross-sectional study was conducted on a sample of consecutive who developed CIN after primary PCI at a tertiary care cardiac hospital in Karachi, Pakistan. The CIN was defined as either a relative increase of 25% or an absolute increase of 0.5 mg/dL in post -procedure serum creatinine within 72 hours. The in-hospital mortality status was recorded and clinical and demographic predictors of in-hospital mortality were identified with the help of binary logistic regression analysis. RESULTS: In the study sample of 402 patients, 74.1% (298) were male and the mean age of the study sample was 59.4±11.5 years. The in-hospital mortality rate was 9.7% (39). On multivar iable analysis, an increased risk of mortality was found to be independently associated with inferior wall myocardial infarction (IWMI) with right ventricular (RV) infarction, intra-procedure arrhythmias, and pump failure with an adjusted odds ratio of 3.63 [95% CI: 1.31-10.08; p=0.013], 5.53 [95% CI: 1.39-22.06; p=0.015], and 8.94 [95% CI: 3.99-20.02; p<0.001], respectively. CONCLUSIONS: In conclusion, there is a high rate of mortality for patients who develop CIN after primary PCI, and the risk of mortality is further aggravated by the presence of IWMI with RV infarction, intra-procedure arrhythmias, and pump failure.