Microvascular dysfunction following deferred stenting strategy in ST-segment elevation myocardial infarction: a case report
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PROVIDER: S-EPMC10686532 | biostudies-literature | 2023 Nov
REPOSITORIES: biostudies-literature
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Project description:A number of studies have evaluated the efficacy of deferred stenting vs immediate stenting in patients with ST-segment elevation myocardial infarction, but the findings were not consistent across these studies. This meta-analysis aims to assess optimal treatment strategies in patient with ST-segment elevation myocardial infarction. We searched the PubMed, EMBASE, and the Cochrane Library for studies that assessed deferred vs immediate stenting in patients with ST-segment elevation myocardial infarction. Nine studies including 1456 patients in randomized controlled trials and 719 patients in observational studies were included in the meta-analysis. No significant differences were observed in the incidence of no- or slow-reflow between deferred stenting and immediate stenting in randomized controlled trials (odds ratio [OR] 0.51, 95%CI 0.17-1.53, P=0.23, I2=70%) but not in observational studies (OR 0.13, 95%CI 0.06-0.31, P<0.0001, I2=0%). Deferred stenting was associated with an increase in long-term left ventricular ejection fraction (weighted mean difference 1.90%, 95%CI 0.77-3.03, P=0.001, I2=0%). No significant differences were observed in the rates of major adverse cardiovascular events (OR 0.53, 95%CI 0.27-1.01, P=0.06 [randomized OR 0.98, 95%CI 0.73-1.30, P=0.87, I2=0%; nonrandomized OR 0.30, 95%CI 0.15-0.58, P=0.0004, I2=0%]), major bleeding (OR=0.1.61, 95%CI 0.70-3.69, P=0.26, I2=0%), death (OR=0.78, 95%CI 0.53-1.15, P=0.22, I2=0%), MI (OR=0.97, 95%CI 0.34-2.78, P=0.96, I2=35%) and target vessel revascularization (OR 0.97, 95%CI 0.40-2.37, P=0.95, I2=24%), between deferred and immediate stenting. Compared with immediate stenting, a deferred-stenting strategy did not reduce the occurrence of no- or slow-reflow, death, myocardial infarction, or repeat revascularization compared with immediate stenting in patients with ST-segment elevation myocardial infarction, but showed an improved left ventricular function in the long term.
| S-EPMC5524015 | biostudies-literature
Project description:BackgroundST-segment elevation myocardial infarction (STEMI) is treated with stenting, but the underlying stenosis is often not severe, and stenting may potentially be omitted.AimsThe aim of the study was to investigate outcomes of patients with STEMI treated with percutaneous coronary intervention (PCI) without stenting.MethodsPatients were identified through the DANAMI-3-DEFER study. Stenting was omitted in the patients with stable flow after initial PCI and no significant residual stenosis on the deferral procedure, who were randomised to deferred stenting. These patients were compared to patients randomised to conventional PCI treated with immediate stenting. The primary endpoint was a composite of all-cause mortality, recurrent myocardial infarction (MI), and target vessel revascularisation (TVR).ResultsOf 603 patients randomised to deferred stenting, 84 were treated without stenting, and in patients randomised to conventional PCI (n=612), 590 were treated with immediate stenting. Patients treated with no stenting had a median stenosis of 40%, median vessel diameter of 2.9 mm, and median lesion length of 11.4 mm. During a median follow-up of 3.4 years, the composite endpoint occurred in 14% and 16% in the no and immediate stenting groups, respectively (unadjusted hazard ratio [HR] 0.87, 95% confidence interval [CI]: 0.48-1.60; p=0.66). The association remained non-significant after adjusting for confounders (adjusted HR 0.53, 95% CI: 0.22-1.24; p=0.14). The rates of TVR and recurrent MI were 2% vs 4% (p=0.70) and 4% vs 6% (p=0.43), respectively.ConclusionsPatients with STEMI, with no significant residual stenosis and stable flow after initial PCI, treated without stenting, had comparable event rates to patients treated with immediate stenting.
| S-EPMC10241275 | biostudies-literature
Project description:ObjectivesThe aim of this study was to assess whether deferred stenting might reduce no-reflow and salvage myocardium in primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).BackgroundNo-reflow is associated with adverse outcomes in STEMI.MethodsThis was a prospective, single-center, randomized, controlled, proof-of-concept trial in reperfused STEMI patients with ≥1 risk factors for no-reflow. Randomization was to deferred stenting with an intention-to-stent 4 to 16 h later or conventional treatment with immediate stenting. The primary outcome was the incidence of no-/slow-reflow (Thrombolysis In Myocardial Infarction ≤2). Cardiac magnetic resonance imaging was performed 2 days and 6 months after myocardial infarction. Myocardial salvage was the final infarct size indexed to the initial area at risk.ResultsOf 411 STEMI patients (March 11, 2012 to November 21, 2012), 101 patients (mean age, 60 years; 69% male) were randomized (52 to the deferred stenting group, 49 to the immediate stenting). The median (interquartile range [IQR]) time to the second procedure in the deferred stenting group was 9 h (IQR: 6 to 12 h). Fewer patients in the deferred stenting group had no-/slow-reflow (14 [29%] vs. 3 [6%]; p = 0.006), no reflow (7 [14%] vs. 1 [2%]; p = 0.052) and intraprocedural thrombotic events (16 [33%] vs. 5 [10%]; p = 0.010). Thrombolysis In Myocardial Infarction coronary flow grades at the end of PCI were higher in the deferred stenting group (p = 0.018). Recurrent STEMI occurred in 2 patients in the deferred stenting group before the second procedure. Myocardial salvage index at 6 months was greater in the deferred stenting group (68 [IQR: 54% to 82%] vs. 56 [IQR: 31% to 72%]; p = 0.031].ConclusionsIn high-risk STEMI patients, deferred stenting in primary PCI reduced no-reflow and increased myocardial salvage. (Deferred Stent Trial in STEMI; NCT01717573).
| S-EPMC4029071 | biostudies-literature
Project description:We report a patient with angina and no flow-limiting epicardial coronary artery disease who presented with recurrent spontaneous coronary artery dissection resulting in an acute ST-elevation myocardial infarction and evidence of coronary microvascular dysfunction on coronary angiography. We review each condition's pathophysiology and provide a review of the literature for reported associations between these disease processes. <Learning objective: Readers will recognize the considerable overlap of risk factors between patients with spontaneous coronary artery dissection and coronary microvascular dysfunction. Our patient had both conditions underlying her heart disease. We provide a review of the literature regarding the underlying pathophysiology for each condition and underscore possible associations between these disease processes. Further studies are needed to determine a definitive link.>.
| S-EPMC8766347 | biostudies-literature
Project description:We retrospectively investigated the relationship between cardiopulmonary exercise testing (CPET) parameters and coronary microvascular dysfunction (CMD) using a novel angiography-based index of microcirculatory resistance (AccuIMR) in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) with complete revascularization. In 418 patients, the culprit vessel AccuIMR was calculated after successful primary PCI. CPET was conducted 44.04 ± 19.28 days after primary PCI. Overall, 157 patients (37.6%) showed elevated AccuIMR (> 40 U) in the culprit vessels. The LVEF was significantly lower in the CMD group than in the Non-CMD group. The CMD group showed worse results in VO2peak, peak O2-pulse, and VE/VCO2 slope than the Non-CMD group. Spearman correlation analysis suggested that VO2peak (r = -0.354), peak O2-pulse (r = -0.385) and VE/VCO2 slope (r = 0.294) had significant linear correlations with AccuIMR (P < 0.001). Multivariable logistic regression analysis showed that AccuIMR was the independent predictor of reduced VO2peak and elevated VE/VCO2 slope. The proportions of positive and equivocal ECG results and early O2-pulse flattening in the CMD group were significantly higher than those in the Non-CMD group, and AccuIMR was the only independent predictor of these ischemia-relating indicators, suggesting that patients with CMD had significant noninvasively detectable myocardial ischemia.
| S-EPMC11535225 | biostudies-literature
Project description:Myocardial infarction remains the principal cause of death in Europe. In patients with ST-segment-elevation myocardial infarction (STEMI), a promptly revascularization with primary percutaneous intervention (PCI) has transformed prognosis in the last decades. However, despite increasing successful PCI procedures, mortality has remained unchanged in recent years. Also, due to an unsatisfactory reperfusion, some patients have significant myocardial damage and suffer left ventricular adverse remodeling with reduced function-all that resulting in the onset of heart failure with all its inherent clinical and socioeconomic burden. As a consequence of longer ischemic times, distal thrombotic embolization, ischemia-reperfusion injury and microvascular dysfunction, the resultant myocardial infarct size is the major prognostic determinant in STEMI patients. The improved understanding of all the pathophysiology underlying these events has derived to the development of several novel therapies aiming to reduce infarct size and to improve clinical outcomes in these patients. In this article, based on the mechanisms involved in myocardial infarction prognosis, we review the new interventional strategies beyond stenting that may solve the suboptimal results that STEMI patients still experience.
| S-EPMC8469769 | biostudies-literature
Project description:The treatment of ST-segment elevation myocardial infarction (STEMI) has advanced dramatically over the past 30 years since the introduction of reperfusion therapies, such that mechanical reperfusion with primary percutaneous coronary intervention is now the standard of care. With STEMI, as with other forms of acute coronary syndrome, stent deployment in culprit lesions is the dominant form of reperfusion in the developed world and is supported by contemporary guidelines. However, the precise timing of stenting and the extent to which both culprit and non-culprit lesions should be treated continue to be active areas of study. In this review, we revisit key data that support the use of mechanical reperfusion therapy in STEMI patients and explore the optimal timing for and extent of stent implantation in this complex patient group. We also review data surrounding the deleterious effects of untreated residual myocardial ischemia, the importance of complete revascularization, and the recent data exploring culprit-only versus multivessel stenting in the STEMI setting.
| S-EPMC5880555 | biostudies-other
Project description:BackgroundThe predictive value of growth differentiation factor-15 (GDF-15) in coronary microvascular dysfunction (CMD) following primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) patients is unclear.MethodsThis study continuously recruited STEMI patients treated with PPCI at the Chest Pain Center of Qilu Hospital of Shandong University from April 2023 to December 2023. Blood samples were taken before PPCI and the level of circulating GDF-15 was measured by enzyme-linked immunosorbent assay (ELISA), and the patients were divided into CMD and Control group according to angiographic microvascular resistance (AMR) (cut-off value 2.50 mmHg*s/cm). The differences in GDF-15 expression levels between the two groups were compared, and the predictive value of GDF-15 for CMD was systematically evaluated.ResultsA total of 134 patients, with an average age of 59.78 ± 12.69 years and 75.37 % being male, were included in this study. Multivariable logistic regression revealed a significant association between GDF-15 and CMD (adjusted OR = 2.505, 95 % CI: 1.661-3.779, P < 0.001). The area under the curve (AUC) of GDF-15 for CMD was 0.782 (95 % CI: 0.704-0.861), with a sensitivity of 0.795 and specificity of 0.643 in predicting CMD in PPCI. The AUC of the GDF-15 model (Model With GDF-15) was 0.867 (95 % CI: 0.806-0.928), significantly outperforming the clinical baseline model (Model Without GDF-15) (Δ AUC = 0.079, 95 % CI: 0.020-0.138, P = 0.009). Furthermore, the net reclassification improvement (NRI) was 0.854 (95 % CI: 0.543-1.166, P < 0.001), and the integrated discrimination improvement (IDI) was 0.151 (95 % CI: 0.089-0.213, P < 0.001).ConclusionsGDF-15 can serve as a biomarker for predicting the development of CMD in STEMI patients undergoing PPCI.
| S-EPMC11336768 | biostudies-literature
Project description:BackgroundPrevious studies have shown conflicting results on the benefits of deferred stenting (DS) in infarct size and the incidence of microvascular obstruction in patients with ST elevation myocardial infarction (STEMI). However, effect of DS on left ventricular (LV) function was not known. We aimed to evaluate whether DS improve LV function and relevant clinical outcomes after STEMI, using follow-up data from the INNOVATION study (NCT02324348).MethodsIn total, 114 patients were randomly assigned to DS group or immediate stenting (IS) group at a 1:1 ratio. LV functional remodeling indices and MACE (major adverse cardiac events: a composite of death, non-fatal MI, unplanned target vessel revascularization, or hospitalization due to heart failure) were compared between DS and IS groups.ResultsSerial echocardiographic analyses were completed in 89 subjects (78%). There were no significant changes in LV volume in either group. While LV ejection fraction and wall motion score index (WMSI) improved in both groups during follow-up, the increments were not statistically different between the 2 groups (4.3 ± 8.2 vs 3.2 ± 7.1, P = .504 for ΔLV ejection fraction; -0.16 ± 0.25 vs -0.16 ± 0.25, P = .99 for ΔWMSI). However, E/e'' was decreased and e' was increased only in the DS group (-3.31 ± 5.60 vs -0.46 ± 3.10, P = .005 for ΔE/e'; 0.77 ± 1.71 vs -0.22 ± 1.64, P = .009 for Δe'). The incidence of major adverse cardiac events was numerically lower in the DS group than in the IS group without a statistical significance at 1-year follow-up.ConclusionsRoutine DS improved LV diastolic function but not systolic function compared with IS in patients with STEMI.
| S-EPMC8284705 | biostudies-literature
Project description:BackgroundEndothelial and microvascular dysfunction are frequently found in the non-culprit territory in patients with acute myocardial infarction (AMI). We aimed to determine whether an impaired coronary physiology of the non-culprit territory impacts long-term prognosis.MethodsFISIOIAM was an observational single-center study which included patients with AMI and another coronary artery lesion in a different territory. Intracoronary physiology of the non-culprit artery was analyzed early after primary percutaneous coronary intervention of the culprit artery, using fractional flow reserve (FFR), index of microcirculatory resistance (IMR), coronary flow reserve (CFR), endothelium-dependent CFR (eCFR) and macrovascular endothelial function . Patients were followed for a composite outcome of cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and hospitalization due to heart failure or unstable angina.ResultsA total of 84 patients (mean age: 62 ± 10 years) were included and functional abnormalities were detected in 93% of them. During follow-up (median of 1422 days; interquartile range, 1287-1634), 13.1% of the patients experienced at least one adverse cardiovascular event. Kaplan-Meier analysis revealed that patients with a CFR < 2 had a higher risk of events (Hazard Ratio, HR: 4.97, 95% Confidence Interval, CI, 1.32-18.75), whereas other parameters such as FFR, IMR, eCFR, and macrovascular endothelial function had no effect. A low CFR was an independent predictor of cardiovascular events, even after adjustment for age and traditional cardiovascular risk factors (adjusted HR: 6.62, 95% CI, 1.30-33.70).ConclusionsThe presence of abnormal coronary microvascular function as measured by a CFR < 2 in the non-culprit territory predicts future risk of adverse cardiovascular events.
| S-EPMC8927849 | biostudies-literature