Thomas Stiermaier

The challenges and impact of microvascular injury in ST-elevation myocardial infarction

ABSTRACT Despite successful restoration of epicardial coronary blood flow, a significant proportion of patients with ST-elevation myocardial infarction suffer from an impairment of the microvascular perfusion – a phenomenon termed no-reflow or microvascular injury (MVI). The underlying pathophysiology is complex and likely multifactorial. It is well established that MVI is associated with worse clinical outcome. Although MVI can be detected during coronary intervention and the post-infarction period, its prevention and treatment strategies remain a major challenge since most results of clinical studies have been disappointing so far. This review provides an overview on the main pathophysiological mechanisms of MVI and its diagnostic approaches. Moreover, it will discuss its clinical consequences and current strategies of prevention and treatment.

Relationship Between Diabetes and Ischemic Injury Among Patients with Revascularized ST-Elevation Myocardial Infarction

Studies comparing reperfusion efficacy and myocardial damage between diabetic and non‐diabetic patients with ST‐elevation myocardial infarction (STEMI) are scarce and have reported conflicting results. The aim was to investigate the impact of preadmission diabetic status on myocardial salvage and damage as determined by cardiac magnetic resonance (CMR), and to evaluate its prognostic relevance.

Thrombusaspiration bei Patienten mit akutem Myokardinfarkt

ZusammenfassungDurch Entwicklungen im Bereich der perkutanen Koronarintervention und der Thrombozytenaggregationshemmung sowie durch schnellere „Door-to-balloon“-Zeiten konnte die Therapie des akuten Myokardinfarkts in den letzten Jahren deutlich verbessert werden. Die fehlende myokardiale Perfusion trotz Rekanalisation des Infarktgefäßes stellt jedoch weiterhin ein prognostisch relevantes Problem dar. Die Aspiration von thrombotischem Material im Bereich der Zielläsion zeigte in ersten Studien eine Verbesserung des koronaren Flusses sowie der myokardialen Perfusion und wurde daher in den internationalen Leitlinien empfohlen. Zuletzt konnten jedoch große multizentrische Studien mit klinischen Endpunkten keine Vorteile durch eine routinemäßige Thrombusaspiration bei Patienten mit akutem Myokardinfarkt aufzeigen. Zudem wurde die Sicherheit der Thrombusaspiration aufgrund eines vermehrten Auftretens von Schlaganfällen in Frage gestellt. Dies führte zu einer Herabstufung der Empfehlung in den Leitlinien. Der vorliegende Review fasst die wichtigsten Ergebnisse aus klinischen Studien sowie die derzeitigen Empfehlungen zur Thrombusaspiration bei Patienten mit akutem Myokardinfarkt zusammen.AbstractRecent advances in percutaneous coronary intervention and antiplatelet therapy as well as faster door-to-balloon times have markedly improved the therapy of patients with acute myocardial infarction. However, impaired myocardial perfusion despite revascularization of the infarcted vessel remains an ongoing problem with high prognostic relevance. In initial clinical trials thrombus aspiration in addition to conventional percutaneous coronary intervention demonstrated benefits regarding coronary flow and myocardial perfusion and was therefore recommended in practice guidelines. These improvements in surrogate endpoints did not translate into a favorable clinical outcome in recent large-scale multicenter randomized trials investigating the routine use of thrombus aspiration in patients with acute myocardial infarction. Furthermore, an increased risk of stroke after thrombus aspiration raises safety concerns. Therefore, thrombus aspiration has been downgraded in the recent guideline updates. The current article reviews the evidence from clinical trials and the recommendations in practice guidelines regarding thrombus aspiration in acute myocardial infarction.

Antithrombozytäre oder antikoagulative Strategie nach chirurgischer/interventioneller Klappenbehandlung

At the end of August 2017 the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) published new joint guidelines for the treatment of valvular heart disease. These guidelines incorporate the scientific progress since the last version of the guidelines published in 2012. This article reviews current guideline recommendations for antiplatelet and anticoagulative therapy after surgical/interventional treatment of the aortic and mitral valves and discusses the underlying scientific evidence.ZusammenfassungEnde August 2017 publizierte die europäische kardiologische Gesellschaft (European Society of Cardiology, ESC) gemeinsam mit der europäischen Gesellschaft für Herz- und thorakale Gefäßchirurgie (European Association for Cardio-Thoracic Surgery, EACTS) neue Leitlinien zur Behandlung von Klappenerkrankungen. Diese Leitlinien berücksichtigen neue wissenschaftliche Erkenntnisse, die seit der letzten Leitlinienversion 2012 verfügbar sind. Diese Übersichtsarbeit berichtet über die aktuellen Empfehlungen zur antithrombozytären und antikoagulativen Therapie nach chirurgischer/interventioneller Behandlung der Aorten- und Mitralklappe und diskutiert die zugrunde liegende wissenschaftliche Evidenz.AbstractAt the end of August 2017 the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) published new joint guidelines for the treatment of valvular heart disease. These guidelines incorporate the scientific progress since the last version of the guidelines published in 2012. This article reviews current guideline recommendations for antiplatelet and anticoagulative therapy after surgical/interventional treatment of the aortic and mitral valves and discusses the underlying scientific evidence.

Intramyocardial haemorrhage and prognosis after ST-elevation myocardial infarction

Aims To evaluate the prognostic value of intramyocardial haemorrhage (IMH) depicted by T2* imaging for risk stratification in ST-elevation myocardial infarction (STEMI) patients in comparison with established cardiac magnetic resonance (CMR) prognosis markers. Methods and results This multicentre study enrolled 264 patients reperfused within 12 h after symptom onset. CMR was performed within the first week after STEMI to assess left ventricular function and infarct characteristics including IMH. The primary endpoint was a composite of death, reinfarction, and new congestive heart failure (major adverse cardiac events, MACE) at 12 months. MACE occurred in 19 patients (7.2%) showing a higher prevalence of IMH when compared with patients without MACE (47% vs. 21%, P = 0.008). The presence of IMH (n = 60, 23%) was independently associated with MACE after adjusting for clinical risk factors [hazard ratio 2.7, 95% confidence intervals (CIs) 1.1-6.6; P = 0.032] or other CMR prognosis markers (hazard ratio 3.1, 95% CI 1.2-7.7; P = 0.013). The addition of IMH to a model of prognostic CMR parameters (ejection fraction, infarct size, and microvascular obstruction) led to net reclassification improvement of 0.42 (95% CI 0.11-0.73, P = 0.009). Conclusion IMH assessed by T2* imaging may provide prognostic information that is incremental to other CMR markers of infarct severity and classical clinical risk factors. IMH could therefore be relevant as an important prognostic measure as well as therapeutic target when caring for patients after STEMI.

Thrombusaspiration bei Patienten mit akutem Myokardinfarkt@@@Thrombus aspiration in patients with acute myocardial infarction: Wissenschaftliche Evidenz und Empfehlungen in den Leitlinien@@@Scientific evidence and guideline recommendations

ZusammenfassungDurch Entwicklungen im Bereich der perkutanen Koronarintervention und der Thrombozytenaggregationshemmung sowie durch schnellere „Door-to-balloon“-Zeiten konnte die Therapie des akuten Myokardinfarkts in den letzten Jahren deutlich verbessert werden. Die fehlende myokardiale Perfusion trotz Rekanalisation des Infarktgefäßes stellt jedoch weiterhin ein prognostisch relevantes Problem dar. Die Aspiration von thrombotischem Material im Bereich der Zielläsion zeigte in ersten Studien eine Verbesserung des koronaren Flusses sowie der myokardialen Perfusion und wurde daher in den internationalen Leitlinien empfohlen. Zuletzt konnten jedoch große multizentrische Studien mit klinischen Endpunkten keine Vorteile durch eine routinemäßige Thrombusaspiration bei Patienten mit akutem Myokardinfarkt aufzeigen. Zudem wurde die Sicherheit der Thrombusaspiration aufgrund eines vermehrten Auftretens von Schlaganfällen in Frage gestellt. Dies führte zu einer Herabstufung der Empfehlung in den Leitlinien. Der vorliegende Review fasst die wichtigsten Ergebnisse aus klinischen Studien sowie die derzeitigen Empfehlungen zur Thrombusaspiration bei Patienten mit akutem Myokardinfarkt zusammen.AbstractRecent advances in percutaneous coronary intervention and antiplatelet therapy as well as faster door-to-balloon times have markedly improved the therapy of patients with acute myocardial infarction. However, impaired myocardial perfusion despite revascularization of the infarcted vessel remains an ongoing problem with high prognostic relevance. In initial clinical trials thrombus aspiration in addition to conventional percutaneous coronary intervention demonstrated benefits regarding coronary flow and myocardial perfusion and was therefore recommended in practice guidelines. These improvements in surrogate endpoints did not translate into a favorable clinical outcome in recent large-scale multicenter randomized trials investigating the routine use of thrombus aspiration in patients with acute myocardial infarction. Furthermore, an increased risk of stroke after thrombus aspiration raises safety concerns. Therefore, thrombus aspiration has been downgraded in the recent guideline updates. The current article reviews the evidence from clinical trials and the recommendations in practice guidelines regarding thrombus aspiration in acute myocardial infarction.