Jiri Knot

Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries

Aims Patient access to reperfusion therapy and the use of primary percutaneous coronary intervention (p-PCI) or thrombolysis (TL) varies considerably between European countries. The aim of this study was to obtain a realistic contemporary picture of how patients with ST elevation myocardial infarction (STEMI) are treated in different European countries. Methods and results The chairpersons of the national working groups/societies of interventional cardiology in European countries and selected experts known to be involved in the national registries joined the writing group upon invitation. Data were collected about the country and any existing national STEMI or PCI registries, about STEMI epidemiology, and treatment in each given country and about PCI and p-PCI centres and procedures in each country. Results from the national and/or regional registries in 30 countries were included in this analysis. The annual incidence of hospital admission for any acute myocardial infarction (AMI) varied between 90–312/100 thousand/year, the incidence of STEMI alone ranging from 44 to 142. Primary PCI was the dominant reperfusion strategy in 16 countries and TL in 8 countries. The use of a p-PCI strategy varied between 5 and 92% (of all STEMI patients) and the use of TL between 0 and 55%. Any reperfusion treatment (p-PCI or TL) was used in 37–93% of STEMI patients. Significantly less reperfusion therapy was used in those countries where TL was the dominant strategy. The number of p-PCI procedures per million per year varied among countries between 20 and 970. The mean population served by a single p-PCI centre varied between 0.3 and 7.4 million inhabitants. In those countries offering p-PCI services to the majority of their STEMI patients, this population varied between 0.3 and 1.1 million per centre. In-hospital mortality of all consecutive STEMI patients varied between 4.2 and 13.5%, for patients treated by TL between 3.5 and 14% and for patients treated by p-PCI between 2.7 and 8%. The time reported from symptom onset to the first medical contact (FMC) varied between 60 and 210 min, FMC-needle time for TL between 30 and 110 min, and FMC-balloon time for p-PCI between 60 and 177 min. Conclusion Most North, West, and Central European countries used p-PCI for the majority of their STEMI patients. The lack of organized p-PCI networks was associated with fewer patients overall receiving some form of reperfusion therapy.

Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy?

Aims The current guidelines recommend reperfusion therapy in acute myocardial infarction (AMI) with ST-segment elevation or left bundle branch block (LBBB). Surprisingly, the right bundle branch block (RBBB) is not listed as an indication for reperfusion therapy. This study analysed patients with AMI presenting with RBBB [with or without left anterior hemiblock (LAH) or left posterior hemiblock (LPH)] and compared them with those presenting with LBBB or with other electrocardiographic (ECG) patterns. The aim was to describe angiographic patterns and primary angioplasty use in AMI patients with RBBB. Methods and results A cohort of 6742 patients with AMI admitted to eight participating hospitals was analysed. Baseline clinical characteristics, ECG patterns, coronary angiographic, and echocardiographic data were correlated with the reperfusion therapies used and with in-hospital outcomes. Right bundle branch block was present in 6.3% of AMI patients: 2.8% had RBBB alone, 3.2% had RBBB + LAH, and 0.3% had RBBB + LPH. TIMI flow 0 in the infarct-related artery was present in 51.7% of RBBB patients vs. 39.4% of LBBB patients (P = 0.023). Primary percutaneous coronary intervention (PCI) was performed in 80.1% of RBBB patients vs. 68.3% of LBBB patients (P< 0.001). In-hospital mortality of RBBB patients was similar to LBBB (14.3 vs. 13.1%, P = 0.661). Patients with new or presumably new blocks had the highest (LBBB 15.8% and RBBB 15.4%) incidence of cardiogenic shock from all ECG subgroups. Percutaneous coronary intervention was done more frequently (84.8%) in patients with new or presumably new RBBB when compared with other patients with blocks (old RBBB 66.0%, old LBBB 62.3%, new or presumably new LBBB 73.0%). In-hospital mortality was highest (18.8%) among patients presenting with new or presumably new RBBB, followed by new or presumably new LBBB (13.2%), old LBBB (10.1%), and old RBBB (6.4%). Among 35 patients with acute left main coronary artery occlusion, 26% presented with RBBB (mostly with LAH) on the admission ECG. Conclusion Acute myocardial infarction with RBBB is frequently caused by the complete occlusion of the infarct-related artery and is more frequently treated with primary PCI when compared with AMI + LBBB. In-hospital mortality of patients with AMI and RBBB is highest from all ECG presentations of AMI. Restoration of coronary flow by primary PCI may lead to resolution of the conduction delay on the discharge ECG. Right bundle branch block should strongly be considered for listing in future guidelines as a standard indication for reperfusion therapy, in the same way as LBBB.

Prasugrel versus Ticagrelor in Patients with Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: Multicenter Randomized PRAGUE-18 Study

Background: No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y12 inhibitors were first demonstrated relative to clopidogrel. Methods: This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total follow-up will be 1 year for all patients and will be completed in 2017. Results: The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0.55–1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53–2.15; P=0.864). Conclusions: This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial. Clinical Trial Registration: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02808767.

Stent Thrombosis—Risk Assessment and Prevention

The development and use of stents has made percutaneous coronary intervention an effective (less restenosis), safe (treatment of emergency vessel closure during balloon angioplasty), and applicable (stents were developed for lesions of tortuous anatomy and complex situations) revascularization method. These features have firmly established stenting as first-line therapy in coronary revascularization. This life-saving device carries, however, the risk of a life-threatening complication--stent thrombosis. The article summarizes the facts about the incidence, histopathology, and risk factors of bare-metal as well as drug-eluting stent thrombosis. Future directions in reducing the incidence of stent thrombosis are also outlined.

Age – related treatment strategy and long-term outcome in acute myocardial infarction patients in the PCI era

BackgroundOlder age, as a factor we cannot affect, is consistently one of the main negative prognostic values in patients with acute myocardial infarction. One of the most powerful factors that improves outcomes in patients with acute coronary syndromes is the revascularization preferably performed by percutaneous coronary intervention. No data is currently available for the role of age in large groups of consecutive patients with PCI as the nearly sole method of revascularization in AMI patients. The aim of this study was to analyze age-related differences in treatment strategies, results of PCI procedures and both in-hospital and long-term outcomes of consecutive patients with acute myocardial infarction.MethodsRetrospective multicenter analysis of 3814 consecutive acute myocardial infarction patients divided into two groups according to age (1800 patients ≤ 65 years and 2014 patients > 65 years). Significantly more older patients had a history of diabetes mellitus and previous myocardial infarctions.ResultsThe older population had a significantly lower rate of coronary angiographies (1726; 95.9% vs. 1860; 92.4%, p < 0.0001), PCI (1541; 85.6% vs. 1505; 74.7%, p < 0.001), achievement of optimal final TIMI flow 3 (1434; 79.7% vs. 1343; 66.7%, p < 0.001) and higher rate of unsuccessful reperfusion with final TIMI flow 0-1 (46; 2.6% vs. 78; 3.9%, p = 0.022). A total of 217 patients (5.7%) died during hospitalization, significantly more often in the older population (46; 2.6% vs. 171; 8.5%, p < 0.001). The long-term mortality (data for 2847 patients from 2 centers) was higher in the older population as well (5 years survival: 86.1% vs. 59.8%). Though not significantly different and in contrast with PCI, the presence of diabetes mellitus, previous MI, final TIMI flow and LAD, as the infarct-related artery, had relatively lower impact on the older patients. Severe heart failure on admission (Killip III-IV) was associated with the worst prognosis in the whole group of patients, though its significance was higher in the youngers (HR 6.04 vs. 3.14, p = 0.051 for Killip III and 12.24 vs. 5.65, p = 0.030 for Killip IV). We clearly demonstrated age as a strong discriminator for the whole population of AMI patients.ConclusionsIn a consecutive AMI population, the older group (>65 years) was associated with a less pronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomy by coronary angiography and proceed to PCI if suitable regardless of age is crucial in all patients, though the primary success rate of PCI in the older age is lower. Age, when viewed as a risk factor, was a dominant discriminating factor in all patients.

Comparison of outcomes in ST-segment depression and ST-segment elevation myocardial infarction patients treated with emergency PCI: data from a multicentre registry

Background Traditionally, acute myocardial infarction (AMI) has been described as either STEMI (ST-elevation myocardial infarction) or non-STEMI myocardial infarction. This classification is historically related to the use of thrombolytic therapy, which is effective in STEMI. The current era of widespread use of coronary angiography (CAG), usually followed by primary percutaneous coronary intervention (PCI) puts this classification system into question. Objectives To compare the outcomes of patients with STEMI and ST-depression myocardial infarction (STDMI) who were treated with emergency PCI. Methods This multicentre registry enrolled a total of 6 602 consecutive patients with AMI. Patients were divided into the following subgroups: STEMI (n = 3446), STDMI (n = 907), left bundle branch block (LBBB) AMI (n = 241), right bundle branch block (RBBB) AMI (n = 338) and other electrocardiographic (ECG) AMI (n = 1670). Baseline and angiographic characteristics were studied, and revascularisation therapies and in-hospital mortality were analysed. Results Acute heart failure was present in 29.5% of the STDMI vs 27.4% of the STEMI patients (p < 0.001). STDMI patients had more extensive coronary atherosclerosis than patients with STEMI (three-vessel disease: 53.1 vs 30%, p < 0.001). The left main coronary artery was an infract-related artery (IRA) in 6.0% of STDMI vs 1.1% of STEMI patients (p < 0.001). TIMI flow 0–1 was found in 35.0% of STDMI vs 66.0% of STEMI patients (p < 0.001). Primary PCI was performed in 88.1% of STEMI (with a success rate of 90.8%) vs 61.8% of STDMI patients (with a success rate of 94.5%) (p = 0.012 for PCI success rates). In-hospital mortality was not significantly different (STDMI 6.3 vs STEMI 5.4%, p = 0.330). Conclusion These data suggest that similar strategies (emergency CAG with PCI whenever feasible) should be applied to both these types of AMI.

Selection of P2Y12 antagonist, treatment initiation, and predictors of high on-treatment platelet reactivity in a "Real World" registry

OBJECTIVE The present study aimed to compare characteristics related to selection of a P2Y₁₂ antagonist, investigate initiation of therapy with new-generation drugs, and identify predictors of high on-treatment platelet reactivity (HTPR) in patients with acute coronary syndrome treated with stent percutaneous coronary intervention (PCI). METHODS AND RESULTS Data from 589 patients in the LAPCOR (Laboratory AntiPlatelet efficacy and Clinical Outcome Registry; ClinicalTrials.gov Identifier: NCT02264912) registry was analyzed. P2Y₁₂ receptor antagonist efficacy was measured by VASP phosphorylation 24 ± 4 hours after a loading dose of clopidogrel (600 mg, N=407), prasugrel (60 mg, N=106), or ticagrelor (180 mg, N=76) and expressed by platelet reactivity index (PRI). HTPR was defined as PRI ≥50%. Patients treated with prasugrel were significantly younger and had significantly higher hemoglobin levels than those who received clopidogrel or ticagrelor, while chronic kidney disease was significantly more prevalent in the ticagrelor group. Almost all invasively managed patients given new-generation drugs received a loading dose after coronary angiography. Mean residual PRI and HTPR were significantly higher after clopidogrel (44.2 ± 23.1% and 42.2%, respectively) vs. prasugrel (17.7 ± 18.0% and 9.4%, respectively) or ticagrelor (18.8 ± 17.0% and 7.9%, respectively; all p<0.001). Among multiple variables tested, HTPR in patients treated with the new agents significantly related only to platelet count (p=0.014) and mean platelet volume (p=0.03). CONCLUSION Safety is the most important aspect under consideration in choosing new agents for an individual patient. Other than platelet count and mean platelet volume, factors known as predictors of higher platelet reactivity, did not influence the efficacy of new-generation P2Y₁₂ receptor antagonists.

Near‐normal coronary angiography in a patient, who is entirely asymptomatic 24 years after successful intracoronary thrombolysis for ST elevation myocardial infarction. Follow‐up of the historically first Czech intracoronary thrombolysis patient

Extremely long‐term follow‐up (24 years) of the historically first Czech myocardial infarction patient, treated by intracoronary thrombolysis, is presented. His current coronary angiography confirmed the finding 24 years ago, that this was a case of smoking‐induced thrombosis in otherwise healthy coronary arteries. Experience with 76 similar cases among 4093 consecutive coronary angiograms (including 778 done acutely for STEMI) is briefly described.

REVIEW: Stent Thrombosis—Risk Assessment and Prevention

The development and use of stents has made percutaneous coronary intervention an effective (less restenosis), safe (treatment of emergency vessel closure during balloon angioplasty), and applicable (stents were developed for lesions of tortuous anatomy and complex situations) revascularization method. These features have firmly established stenting as first-line therapy in coronary revascularization. This life-saving device carries, however, the risk of a life-threatening complication--stent thrombosis. The article summarizes the facts about the incidence, histopathology, and risk factors of bare-metal as well as drug-eluting stent thrombosis. Future directions in reducing the incidence of stent thrombosis are also outlined.

Relationship between TRAIL and Left Ventricular Ejection Fraction in Patients with ST-Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention

Background Apoptosis plays an important role in the myocardial injury after acute myocardial infarction and in the subsequent development of heart failure. Aim To clarify serum kinetics of apoptotic markers TRAIL and sFas and their relation to left ventricular ejection fraction (LVEF) in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Methods In 101 patients with STEMI treated with pPCI, levels of TRAIL and sFas were measured in series of serum samples obtained during hospitalization and one month after STEMI. LVEF was assessed at admission and at one month. Major adverse cardiovascular events (MACE, i.e., death, re-MI, and hospitalization for heart failure and stroke) were analysed during a two-year followup. Results Serum level of TRAIL significantly decreased one day after pPCI (50.5pg/mL) compared to admission (56.7pg/mL), subsequently increased on day 2 after pPCI (58.8pg/mL), and reached its highest level at one month (70.3pg/mL). TRAIL levels on days 1 and 2 showed a significant inverse correlation with troponin and a significant positive correlation with LVEF at baseline. Moreover, TRAIL correlated significantly with LVEF one month after STEMI (day 1: r=0.402, p<0.001; day 2: r=0.542, p<0.001). On the contrary, sFas level was significantly lowest at admission (5073pg/mL), increased one day after pPCI (6370pg/mL), and decreased on day 2 (5548pg/mL). Significantly highest sFas level was marked at one month (7024pg/mL). sFas failed to correlate with LVEF at baseline or at one month. Both TRAIL and sFas showed no ability to predict improvement of LVEF one month after STEMI or a 2-year MACE (represented by 3.29%). Conclusion In STEMI treated with pPCI, TRAIL reaches its lowest serum concentration after reperfusion. Low TRAIL level is associated with worse LVEF in the acute phase of STEMI as well as one month after STEMI. Higher TRAIL level appears to be beneficial and thus TRAIL seems to represent a protective mediator of post-AMI injury.