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The β1-blocker when administered before reperfusion activates myocyte prosurvival signaling via β2-adrenergic receptor (β2-AR) and protein kinase A (PKA)-dependent mechanism during ischemia/reperfusion (I/R). The heart is endowed with powerful self-protective ability executed by endogenous β2-adrenopeptide receptor activation. I/R triggers cardiac epinephrine and neuropeptide calcitonin gene-related peptide (CGRP) release. Cardiac β1- and β2-AR stimulation mediates pro- and anti-apoptotic cell signaling, respectively. Removal of myocardial β1-AR-derived proapoptotic force with β1-AR blockade unmasks the dominance of β2-AR mediated prosurvival cell signaling through the well-defined PKA-Akt dependent mechanism. This review focuses on recent clinical and experimental findings including intrinsic cardiac β2-adrenopeptide neuroparacrine signaling mechanisms involved in I/R injury protection. While β2-adrenopeptide-mediated cardioprotection is important, age-related β2-adrenopeptide receptor decoupling can result in their ineffectiveness in response to the receptor-specific therapies. Accordingly, direct activation of receptor-coupled upstream PKA-dependent signaling may serve as a therapeutic alternative to achieve cardioprotection bypassing adrenopeptidergic receptor decoupling accompanied with aging. Phosphodiesterase-3 (PDE3) inhibitor reduces infarct-size via cAMP-dependent PKA signaling. Non-β1-AR-mediated PKA activation activates multiple prosurvival signaling pathways eventually leading to Akt activation. Combination therapy with β1-blocker esmolol and PDE3 inhibitor milrinone additively reduced infarct-size in preclinical studies. Concurrent β1-AR blockade and PDE3 inhibition provides complementary synergy with promising therapeutic potential in patients with acute myocardial infarction and beyond.

Impaired renal function and anaemia are common among patients with acute myocardial infarction (AMI). While both conditions are known independent risk factors for increased mortality, their interaction as risk factors for increased mortality in AMI is unclear.We studied 5395 subjects hospitalized for AMI between January 2000 and December 2005. An estimated glomerular filtration rate (GFR)60 mL/min/1.73 m(2) was defined as impaired GFR and GFR ≥ 60 mL/min/1.73 m(2) was defined as preserved GFR. Anaemia was defined as13 g/dL (males) and12 g/dL (females). The odds ratio (OR) for one-year mortality and its 95% confidence interval (CI) were calculated by logistic regression.We identified 758 (14%) patients with impaired GFR and anaemia, 1105 (20.5%) patients with impaired GFR without anaemia, 465 (8.6%) patients with preserved GFR and anaemia, and 3012 (55.8%) patients with preserved GFR without anaemia; one-year mortality rates were 56.5%, 41.8%, 31.8% and 10.3% respectively in these 4 groups. Among patients with impaired GFR, anaemia was associated with an adjusted OR of 1.47 (95% CI=1.17-1.85) for one-year mortality, while among patients with preserved GFR, anaemia was associated with a higher adjusted OR of 2.07 (95% CI=1.54-2.76) for one-year mortality, interaction P0.001.The combination of impaired GFR and anaemia confers greater than five-fold increased risk of mortality after AMI. The differential effect of anaemia among patients with impaired and preserved GFR on mortality suggests that in patients with preserved GFR anaemia confers a greater relative hazard than in patients with impaired renal function.

We investigated the differences in socioeconomic status and quality health care between Singapore-born citizens and immigrants presenting with ST-segment elevation myocardial infarction (STEMI).In a prospective study, patients admitted with STEMI were recruited for a questionnaire survey. The recruited patients were categorized based on their immigration status into Singapore-born citizens (SBC), foreign-born citizens (FBC), permanent residents (PR) and non-residents (NR).Among the 374 recruited patients, 286 (76.5%) patients were categorized as SBC, and the remaining 88 (23.5%) as immigrants. Further breakdown of the immigrants revealed that 33 were FBC (median duration of living in Singapore, 53 years), 22 were PR (18 years), and 33 were NR (11 years). Significant differences in socioeconomic status among SBC, FBC, PR and NR were detected. NR were in the lowest, while PR in the highest, socioeconomic class based on occupation (p=0.003), education level (p0.001), and average monthly household income (p=0.020). There were no disparities in the proportion of patients treated with primary PCI (SBC 88%, FBC 82%, PR 91%, NR 79%, p=0.555). Median door-to-balloon times were similar among the four groups (56, 52, 60, 56min, p=0.614). Compared with SBC, PR was associated with longer symptom-to-balloon times (median difference 54.1 min; 95% CI 9.0 to 99.2).There were major differences in the socioeconomic status among SBC, FBC, PR and NR who presented with STEMI. Although there were no major disparities in access to high quality health care to these patients with different immigration status, symptom-to-balloon time differed substantially among the different migrant classes.

Background Drug-eluting stents (DESs) are effective in reducing restenosis and the need for repeat revascularization procedures in patients who undergo percutaneous coronary intervention (PCI). There is however an increased concern with the safety of DES with regard to stent thrombosis (ST). We examined the incidence of ST among patients who received DES and determined the clinical predictors. Methods All patients who underwent PCI in our centre were prospectively enrolled in a cardiovascular database. All cases of ST, as defined by 2006 Academic Research Consortium (ARC) hierarchical classification as definite and probable, from August 2002 to August 2006 were reviewed and analyzed. The clinical, angiographic and procedural characteristics of patients who developed ST were compared with those who did not. Results The study population comprised 1580 patients who received DES implantation. The cumulative incidence of ST was 1.5%: acute ST 0.2%, subacute ST 0.9%, late ST 0.2% and very late ST 0.2%. Mortality and myocardial infarction occurred in 16% and 84% of patients, respectively, as a consequence of ST. Multivariate analysis showed that patients presenting with cardiogenic shock, acute coronary syndrome, presence of multivessel disease, impaired baseline TIMI flow and higher number of stents implanted per lesion were predictive of ST. Conclusion The incidence of DES ST in our ‘real world' registry was low. There were clinical and angiographic characteristics identified as independent predictors of ST.

N-acetylcysteine (NAC) and sodium bicarbonate (SOB) therapies may prevent contrast-induced nephropathy (CIN). However, the efficacy of using combination over individual therapies was not established, and there was no large randomised study comparing abbreviated SOB therapy with conventional sustained saline pre-hydration with oral NAC.In a multi-centre, open-label, randomised, controlled trial (NCT00497328), we prospectively enrolled 548 patients with at least moderate renal impairment undergoing cardiac catheterisation with or without percutaneous coronary intervention. Patients were randomly assigned to 3 groups: 1) NAC: 154 mEq/L sustained sodium chloride regime (1 mL/kg/h 12 h before, during and 6h after the procedure) with oral NAC at 1.2g bid for 3 days (n=185); 2) SOB: 154 mEq/L abbreviated SOB regime at 3 mL/kg/h 1h before the procedure, and 1 mL/kg/h during and 6h after the procedure (n=182); and 3) COM: combination of abbreviated SOB regime and oral NAC (n=181). The primary end point was incidence of CIN. The secondary end points were rise in serum creatinine, hospitalisation duration, haemodialysis, morbidity and mortality within 30 days.The 3 groups had similar baseline characteristics: age 68 ± 10 years, 76% male, 48% diabetic and baseline glomerular filtration rate (GFR) 47.7 ± 13.0 mL/min. There were 41 (8.8%) patients with GFR30. The CIN incidences were NAC 6.5%, SOB 12.8% and COM 10.6%. The COM regimen was not superior to either the NAC (relative risk (RR)=1.61, 95% confidence interval (CI): 0.76 to 3.45, p=0.225) or SOB (RR=0.83, 95% CI: 0.44 to 1.56, p=0.593) regimens. The CIN incidence was lower in the NAC group than the SOB group (adjusted odds ratio (OR)=0.40, 95% CI: 0.17 to 0.92; p=0.032). Multivariate analysis showed contrast volume (OR=1.99, 95% CI: 1.33 to 2.96, p0.001 per 100mL), female (OR=2.47, 95% CI: 1.22 to 5.00, p=0.012) and diabetes (OR=2.03, 95% CI: 1.03 to 3.99, p=0.041) were independent risk predictors. There were no differences in the secondary outcomes among the 3 groups.The combination regimen was not superior to individual regimens in preventing CIN in patients with baseline renal impairment. There was a trend suggesting that the 12-hour sustained sodium chloride pre-hydration regimen was more protective than the 1-hour abbreviated SOB regimen.

plaque content signifies vulnerability and is predictive of subsequent cardiovascular events, our findings were in line with the hypothesis that serum adiponectin level is elevated in a counter-regulatory fashion in advanced coronary artery disease. Yet, in the same study, we found that serum adiponectin levels differed between the three ethnic groups in Singapore [6] .I t was significantly lower in the Indian patients than in the Chinese and Malay patients. Although this explains the known augmented risk of adverse events after coronary revascularization among Indian patients, it argues against the aforementioned necrotic core content theory. In view of the conflicting data on the role of adiponectin and vascular outcomes, we perceived it to be necessary to

1 (0.6) 0 (0.0) 1 (0.6) 2 (0.4) 1.000 Metformin 13 (8.3) 21 (13.7) 14 (9.0) 48 (10.3) 0.248 Methyldopa 2 (1.3) 0 (0.0) 0 (0.0) 2 (0.4) 0.332 Nicotinic acid 1 (0.6) 1 (0.7) 1 (0.6) 3 (0.6) 1.000 Omega 1 (0.6) 1 (0.7) 0 (0.0) 2 (0.4) 0.774 Prasugrel 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.2) 0.328 Propafenone 1 (0.6) 0 (0.0) 0 (0.0) 1 (0.2) 1.000 Rosiglitazone 5 (3.2) 0 (0.0) 0 (0.0) 5 (1.1) 0.012 Spironolactone 17 (10.8) 14 (9.2) 22 (14.1) 53 (11.4) 0.396

We studied the safety and effectiveness of fixed-dose, intracoronary bolus-only abciximab in 195 patients who underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. The patients were divided into 2 groups: Group A (n = 120, 61.5%) received fixed-dose, intracoronary bolus-only, abciximab 10 mg; and Group B (n = 75, 38.5%) received standard intravenous bolus (0.25 mg/kg) and maintenance abciximab infusion of 0.125 μg/kg/min for 12 h. There was no statistically significant difference in the baseline and post-procedure TIMI flow between Groups A and B. Final TIMI 3 flow was achieved in 90.0% and 89.3% of the patients in Groups A and B, respectively (p = 0.14). Final TIMI myocardial perfusion grade 2/3 was achieved in 92.5% and 96.0% of the patients in Groups A and B, respectively (p = 0.45). The six-month clinical outcomes were similar between Groups A and B (8.3% versus 5.3%, p = 0.62).

Background Circulating progenitor cells (CPC) especially endothelial progenitor cell (EPC) levels and functions are attenuated in diabetic patients. This may explain the poorer outcome of diabetics undergoing percutaneous coronary intervention (PCI). We aim to study the dynamic changes of these cells in these patients. Methods Blood of 8 diabetics with stable coronary artery disease who underwent elective PCI, were obtained at baseline, 1, 4 and 24 h after PCI. Fluorescence activated cell sorting (FACS) analysis was performed to quantitate CD34+ and CD34+/ KDR+ cells. Patients with recent acute coronary syndrome were excluded. Results After PCI, decreases in CPC from baseline were detected in 7 out of the 8 patients. In these 7 patients, mean CD34+ and CD34+/KDR+ cells were 182±99/1×10 5 and 18±16/1×10 5 cells respectively. Maximal decrease of CD34+ and CD34+/KDR+ cells were 47.8% and 53.3% at 1 h and 4 h respectively. At 24 h, CPC levels returned to baseline but were not elevated. The only patient with raised cardiac enzymes has instead, 2 to 3 fold increase in CPCs at 1 and 4 h. Conclusions We found a transient dip in circulating progenitors early during PCI. This suggests incorporation of the cells into the sites of vascular denudation. The absence of subsequent CPC elevation post-PCI in diabetes may be associated with known poorer outcome of these patients. With myocardial injury, more progenitors may be mobilized from the bone marrow into the circulation and abolish the hyperacute reduction in circulating levels.

Background There are safety concerns on drug-eluting stents (DESs) using durable polymer. The long-term outcome of next generation DESs using bioabsorbable polymer technology remains unknown. Methods From March to June, 2005, a novel sirolimus-eluting (170 μg/cm2), bioabsorbable polymer (PLA and PLGA, eroded over 45 days) coated stent was implanted for treatment of acute myocardial infarction (AMI) in 49 patients (male 86%, age 55+10 years, diabetes 31%). All culprits were de novo lesions in the native coronary artery. On discharge, aspirin and clopidogrel for 3 months followed by life-long aspirin were prescribed. Angiographic follow-up was performed at 8 months. Clinical follow-up was performed at 4, 9 and 24 months. Results Angiographic success rate was 100%. In-hospital adverse events consisted of 1 death (2%). All except one patient (due to aspirin allergy) were compliant to the 3 months dual antiplatelet therapy, and there was no adverse event during this period. One patient developed re-infarction in another coronary territory at 6 months. Twenty-seven patients (56%) underwent 8-month angiographic follow-up (Table 3). At 24 months, 6 patients had 7 major adverse cardiac events (12.2%, 1 death, 2 re-infarctions and 4 target lesion revascularizations). There were no incidences of subacute or late stent thrombosis. Conclusions The Cura stent, using bioabsorbable polymer technology, appears to be safe at 2 years follow-up. Although the angiographic follow-up parameters were unfavorable, this report paves the way for further studies on DES using bioabsorbable polymer technology.

The current recommended weight-adjusted dosing regimen of unfractionated heparin and target activated clotting time (ACT) in percutaneous coronary intervention (PCI) is based on limited data from the western population, and the applicability in the various Asian ethnic groups remains unknown. This is a retrospective study in an Asian university teaching hospital. Among the 1287 patients who have undergone PCI, Chinese constituted 70.4% (n=906), Malay 15.5% (n=199) and Indian 14.1% (n=182). Overall, the mean total heparin dose was 6224+/-1548 U, mean weight-adjusted heparin dose was 95+/-30 U/kg, and mean ACT was 325+/-95 s. There was no significant difference in the 3 ethnic groups. Both the incidences of in-hospital ischemic complications (Chinese 2.4%, Malay 3.5%, Indian 2.2%, p=0.641) as well as in-hospital bleeding complications (Chinese 4.5%, Malay 3.5%, Indian 6.0%, p=0.490) were similar in the 3 ethnic groups. When the patients were divided based on ACT into 3 groups:250, 250-350 and350 seconds, the incidence of ischemic complication (2.5%, 2.5%, 2.7%) was similar (p=819), while that of bleeding complications (4.1%, 3.5%, 6.8%) showed a strong trend (p=0.057) of increased risk in patients with ACT350 s. In conclusion, the recommended weight-adjusted heparin-dosing regimen in PCI derived from the western population is equally applicable to the Asian patients. ACT does not correlate with in-hospital ischemic complications, but increased bleeding complications were observed with ACT350 s.

CYPHER® sirolimus-eluting stent (Cordis Corporation, FL, USA) and TAXUS® polymer-based paclitaxel-eluting stent (Boston Scientific Corp., Natick, Massachusetts) are the two drug-eluting stents (DESs) approved by the US Food and Drug Administration for clinical use [1,2]. A number of clinical trials comparing the short-term efficacy of these two DESs have been published recently [3–6]. In essence, the results either showed superiority of the CYPHER stent or equivalence of the two, depending on the population and end-points studied. However, data comparing the long-term clinical outcomes of the two DESs, especially in bifurcation lesions, are limited. We previously reported similar procedural success rates and 30-day clinical outcomes between the two DESs in native de novo bifurcation lesions, but with subacute stent thrombosis occurring only in the TAXUS group [7]. In this report, we sought to present the long-term (N2 years) clinical outcomes of the same patient cohort.

Six patients with complete left bundle branch block and an increase in the transverse:frontal plane QRS voltage ratio are described. All these patients presented with congestive heart failure which was due to severe left ventricular dysfunction.

Twelve lead electrocardiograms together with right-sided chest leads V4R, V5R and V6R were recorded in four patients with acute pulmonary embolism. All four patients showed ST segment elevation and a qs or qr pattern (with prominent q waves) in one to three of the leads V4R, V5R and V6R. These abnormalities were absent in the repeat electrocardiograms which were recorded after the acute illness.

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is an uncommon disorder characterized by apical ballooning. The etiology and pathophysiology of this syndrome has not been fully evaluated. This case series examined the clinical characteristics and outcomes of 10 patients with confirmed stress-induced cardiomyopathy. We identified 10 cases of stress-induced cardiomyopathy. All exhibit characteristic apical ballooning and basal hyperkinesia except one with an "inverted Takotsubo" pattern. Coronary angiography excluded coronary artery stenoses as a cause of cardiomyopathy. Patient characteristics, cardiac function, follow-up echocardiography and outcomes were determined. 60% of cases were female and 70% of cases had ST-segment elevations. Identified precipitants included severe emotional stress, subarachnoid haemorrhage and sepsis. None of the cases had angiographically significant coronary stenosis. One patient had an "inverted Takotsubo" pattern with mid-ventricular ballooning. Stress-induced cardiomyopathy is a clinical spectrum which can present with a classical "Takotsubo" or "inverted Takotsubo" pattern. Presentation is varied but characterized by recovery to normal cardiac systolic function. Study of this syndrome may enhance further understanding of the "brain-heart" relationship.

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by the presence in the serum of antibodies against various organs. Patients with SLE have an increased risk of atherosclerosis and thrombosis. Coronary artery disease is now one of the most important causes of death in patients with SLE [1]. It was reported that middleagedwomenwith SLEwere over 50 timesmore likely to have a myocardial infarction (MI) than women of similar age [2]. Apart from traditional risk factors like smoking and diabetes mellitus, SLE patients have other non-traditional risk factors that predispose them to coronary thrombosis. These include the presence of anti-phospholipid antibodies, anti-oxidized low-density lipoprotein antibodies, lipid peroxidation, hyperhomocysteinemia and cumulative SLE activity [3]. Percutaneous coronary intervention (PCI) has been proven to be an effective treatment for obstructive coronary artery disease. Despite an increased risk of developing coronary artery disease, the safety and long-term efficacy of PCI in this specific patient cohort has not been studied. We present the long-term follow-up (N3 years) data of a cohort of SLE patients who have undergone PCI using bare metal stents or drug-eluting stents.

We read with great interest the recent review article on bioresorbable vascular scaffolds by Bourantas et al. and wish to share our institution's experience with the use of the ABSORB bioresorbable vascular scaffold (BVS; Abbott Vascular, Santa Clara, California) [1]. There is currently limited published data on the use of BVS in routine clinical practice andwehaveundertaken a prospective evaluation of this novel device in our institution. All consecutive patients who underwent percutaneous coronary intervention (PCI) with intent for BVS implantation between July 2011 and September 2012were included in the analysis. All patients received dual anti-platelet therapyprior to PCI and this therapywascontinued for at least a year after implantation. This study fulfilled local ethical requirements and written informed consent was obtained from all patients. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Once a suitable lesion was identified, the pre-procedural reference vessel diameter (RVD) was assessed by quantitative coronary analysis (QCA) using the Pie Medical CAAS QCA (quantitative coronary analysis) package in our Xcelera Workstations (Philips Medical Systems, Veenpluis, The Netherlands). Alternative vessel sizing was via the use of commercially available intravascular ultrasound (IVUS) or optical coherence tomography (OCT). A RVD of 2.0 to 3.8 mm and a lesion length of less than 28 mm were considered suitable for BVS (single or overlapping). The availableABSORBBVSwere2.5×18 mm,2.5×28 mm, 3.0×18 mm, 3.0×28 mm, 3.5×12 mm, 3.5×18 mm, or 3.5×28 mm in size. 6 Fr vascular access was used in all patients with a predominant radial access (77.1%). Mandatory predilation with balloon angioplasty using a balloon with a diameter of 0.5 mm smaller or equivalent to the intended BVS size was performed prior to BVS implantation. Device deployment was performed at a rate of ≤2 atm per 5 s up to 16 atm (rated burst pressure). Postdilation was with a non-compliant balloon with diameter≤0.25 mm beyond the implanted BVS if necessary to avoid scaffold damage. For longer lesions or edge dissections, overlapping scaffolds were used. A total of 35 consecutive patients with 41 lesions underwent attempted ABSORB BVS implantation during the study period. Baseline emographics, indications, procedure and quantitative coronary angiography details are summarized in Table 1. The mean age is 54.7± 11.2 years (range 36–86 years) and 85.7% of the patients (n=30) were male. Diabetes mellitus (type I or II) was present in 17.1% (n=6) of the study population. 51.4% of patients presented with an acute coronary syndrome including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). Overall, 45 BVS were successfully implanted in 33 (93.3%) patients (1.4 BVS/patient). Of the 41 lesions treated, the success rate was 100% (22/22) for the left anterior descending artery (LAD), 100% (11/11) for the right coronary artery (RCA), and 75% (6/8) for the left circumflex artery (LCX). Two patients had circumflex (LCX) stenosis not crossable by the BVS despite aggressive lesion preparation with multiple balloon predilations. An equivalent metallic drug eluting stent crossed without difficulty in both cases. The majority, 31 (75.6%), of lesions treated were complex (B2 or C). Pre-procedure RVD was assessed by QCA in 28 patients (80.0%), IVUS in 4 patients (11.4%), andOCT in 3 patients (8.6%). Themeanpre-procedural RVDwas 2.7±0.4 mm, diameter stenosiswas 77.7±13.0%, and lesion lengthwas 17.2±6.7 mm. Post-procedural RVD was 3.0±0.3 mmwith residual diameter stenosis of 2.4±2.0%.

Background and objective: Occlusion of the circumflex coronary artery may present with either ST elevation typical of inferior or lateral myocardial infarction, ST depression or a normal 12-lead electrocardiogram (ECG). In patients presenting with ST depression, concomitant ST elevation in the posterior leads V7, V8 and V9 is believed to reflect ST-elevation myocardial infarction of the posterior wall. However, to be confident of this diagnosis, it is necessary to know that posterior ST depression does not occur in acute subendocardial ischaemia. Methods and results: We have prospectively recorded leads V7, V8 and V9 simultaneously with the standard 12-lead ECG in patients who underwent treadmill stress test. Group A consists of 35 patients who showed ischaemic praecordial ST depression in their 12-lead ECGs during treadmill stress test and subsequent angiographic documentation of significant coronary artery disease. Group B consists of 35 subjects who showed normal ECG findings during treadmill stress test. In none of the Group A or B patients was there ST elevation in leads V7, V8 or V9 either at rest or at peak exercise. ST depression was seen in 69% in V7, 31% in V8 and 11% in V9 in the Group A patients at peak exercise. Conclusion: ST elevation in leads V7, V8 and V9 is uncommon in patients presenting with subendocardial ischaemia. Therefore, in patients presenting with acute chest pain and ST depression in the 12-lead ECG, concomitant posterior ST elevation may be a reliable indicator of ST elevation posterior MI. This is likely due to circumflex artery occlusion and may require thrombolytic therapy.

Distal protection using FilterWire EX has been shown to be effective in reducing the incidence of debris embolization and no-reflow phenomenon in saphenous vein graft (SVG) intervention. We present a case of mechanical obstruction of antegrade flow by atherothrombotic debris collected in the FilterWire EX after stent implantation of the ostial SVG lesion, masqueraded as no-reflow phenomenon. The condition was promptly reverted by thrombosuction using an Export Aspiration Catheter. A heavy debris burden was recovered by the thrombosuction and there was no evidence of myonecrosis after the procedure. We emphasize that different distal protection device can complement each other in special situations. A brief overview of the various approaches in preventing distal embolization in SVG intervention was also given.

Formation of intracoronary thrombus during percutaneous coronary intervention can lead to acute vessel closure and myocardial infarction if prompt action is not taken. Thrombus removal using mechanical thrombectomy is the common treatment approach. We report a rare case of thrombus formation immediately after guidewire advancement, causing acute myocardial ischemia. Intracoronary bolus of abciximab was given and this resulted in prompt dissolution of the thrombus. The procedure proceeded uneventfully and there was no myocardial damage. This is consistent with a recent report suggesting that intracoronary abciximab may be more beneficial than standard intravenous administration for patients undergoing emergency coronary intervention for acute coronary syndrome.

Patients undergoing primary mechanical reperfusion forST elevation myocardial infarction (STEMI) in whomnormal antegrade flow (thrombolysis in myocardial infarc-tion grade 3 [TIMI-3] flow) is present in the culpritepicardial vessel at diagnostic angiography have beenshown to be associated with better outcomes than thosewith impaired antegrade flow (TIMI-0–2) [1]. A recentprospective, randomized study suggests that pre-treatmentwith X-sizer thrombectomy before percutaneous coronaryintervention (PCI) in acute coronary syndrome can improvefinal epicardial flow and accelerate ST-segment recovery[2,3]. In this study, we sought to determine whether X-sizerthrombectomy could abrogate the inferior outcomes inpatients with STEMI in whom initial angiography showedTIMI-0–2 flow.Patients with STEMI who underwent primary mechan-ical reperfusion using X-sizer thrombectomy before PCIbetween November 2000 and February 2003 were analyzed.Patients were selected because of arteriographic evidence ofthrombus. Patients were divided into two groups dependingon whether the initial angiography showed normal (TIMI-3)or impaired (TIMI-0–2) flow.Among the 95 study patients, normal antegrade flow(TIMI-3) was present in 13% (n=12) at initial angiography.For the remaining patients with impaired TIMI flow, 83.1%(n=69) had TIMI-0, 12.1% (n=10) TIMI-1 and 4.8% (n=4)TIMI-2 flow. The demographic, risk factor and treatmentprofiles of the two groups were shown in Table 1. Comparedwith patients without TIMI-3 flow, those with TIMI-3 flowbefore thrombectomy had greater left ventricular ejectionfraction (52F12% versus 43F12%, p=0.05), trend towardslower incidence of cardiogenic shock (0% versus 8.4%,p=0.2) and use of glycoprotein IIbIIIa inhibitors (0% versus