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BackgroundThe pharmacoinvasive (PhI) strategy is the standard-of-care for ST-elevation myocardial infarction (STEMI) patients when primary percutaneous coronary intervention (pPCI) is unfeasible. Optimal timing for post-fibrinolytic PCI (lysis-PCI) remains elusive. Therefore, this study aimed to assess the clinical and economic impacts of early vs. delayed lysis-PCI in patients with STEMI.MethodsThis retrospective cohort study included 1,043 STEMI patients classified by lysis-PCI timing. The primary outcome was in-hospital major adverse cardiovascular events (4p-MACE), with secondary outcomes such as 3p-MACE, in-hospital mortality, and costs. Multivariable logistic regression models were used to assess the association between lysis-PCI timing and outcomes. Cost analyses were conducted from the perspective of Brazilian public healthcare system, with values converted to international dollars (Int$) for broader applicability.ResultsEvery 4-h delay in lysis-PCI was associated with a 44% reduction in in-hospital mortality [OR = 0.560 (95% CI: 0.381–0.775); p = 0.001] and a 13% decrease in 4p-MACE [OR = 0.877 (95% CI: 0.811–0.948); p = 0.001]. Additionally, 4-h delay in lysis-PCI was also associated with a significant reduction in in-hospital costs (Int$916.20 ± 99) and disease-induced years of productivity lost (β = −41.79 ± 151 years; p = 0.001). These significant trends remained consistent even after adjusting for confounders and applying propensity score matching. Older adults (aged ≥80) experienced an increase in 3p-MACE with earlier lysis-PCI.ConclusionDelaying lysis-PCI was found to be associated with reduced in-hospital cardiovascular adverse events and lower costs, particularly among older adults. Further research should develop evidence-based lysis-PCI protocols that optimize both clinical outcomes and cost-effectiveness.

Objectives: This study aimed to determine the incidence, predictors, and clinical outcomes of slow flow and no reflow (SF/NR) in patients undergoing a pharmacoinvasive strategy following full-dose thrombolytic therapy for acute myocardial infarction (AMI). Methodology: We conducted a prospective observational study at the Department of Cardiology, Hayatabad Medical Complex, Peshawar, from February 2022 to February 2023. The study cohort comprised 130 patients who received percutaneous coronary intervention (PCI) after thrombolytic therapy. Comprehensive data on patient demographics, clinical presentations, procedural details, and outcomes were systematically collected. Multivariate logistic regression was employed to identify independent predictors of SF/NR. Results: The incidence of SF/NR was 13.8%. Significant predictors included hypertension (Odds Ratio [OR]: 2.31, 95% Confidence Interval [CI]: 1.01-5.29, p = 0.047), high thrombus burden (OR: 3.14, 95% CI: 1.38-7.15, p = 0.006), and longer lesion length (OR: 1.29 per mm increase, 95% CI: 1.11-1.50, p < 0.001). Patients with SF/NR experienced significantly higher in-hospital mortality (16.7% vs. 2.7%, p = 0.012), cardiogenic shock (27.8% vs. 5.4%, p < 0.001), heart failure (33.3% vs. 7.1%, p < 0.001), and major adverse cardiac events (MACE) (44.4% vs. 11.6%, p < 0.001). At 30 days post-discharge, the mortality rate was 22.2% in the SF/NR group compared to 4.5% in the normal flow group (p = 0.004). Conclusion: The study highlights a significant incidence of SF/NR in patients undergoing PCI after thrombolytic therapy for AMI. Identified predictors--hypertension, high thrombus burden, and longer lesion length--underscore the need for targeted risk stratification and management strategies to enhance patient outcomes and mitigate adverse effects. [ABSTRACT FROM AUTHOR]

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Abstract Background Pharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner. Methods Authors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality. Results A total of 2,710 consecutive STEMI patients aged 59 [51–66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60–210] minutes and the door-to-needle time was 70 [43–115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9–11.8] hours, compared to 15.7 [6.8–22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77–0.84] and GRACE AUC-ROC of 0.86 [0.83—0.89]. Conclusion In a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014.

Background: Pharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner. Methods: Authors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality. Results: A total of 2,710 consecutive STEMI patients aged 59 [51–66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60–210] minutes and the door-to-needle time was 70 [43–115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9–11.8] hours, compared to 15.7 [6.8–22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77–0.84] and GRACE AUC-ROC of 0.86 [0.83—0.89]. Conclusion: In a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014. [ABSTRACT FROM AUTHOR]

ackground: Until now there is no clear evidence to support the superiority of one strategy over the others to treat STEMI patients. Serial B‐type natriuretic peptide (BNP) measurements accurately predict the risk of death or congestive heart failure in STEMI patients. Objective: The aim of the study was to determine which strategy is the best strategy to treat acute STEMI and if BNP give an incremental prognostic value in treated STEMI patients. Patients presented with acute STEMI were enrolled in the present study. Patients and methods: Only 93 patients were followed up with us for 6 months and divided to 3 groups according to the treatment strategy. All patient underwent BNP analysis, echocardiography and treated with either received only thrombolytic therapy (Group I), primary PCI (Group II) or received thrombolytic therapy then went to catheterization (Group III). Results: Regarding BNP level change was higher in Group I and in Group III had high BNP level higher than Group II but this difference doesn`t reach level for statistically significant correlation between BNP levels and type of reperfusion in the three groups. Regarding LV systolic function, there was no statistically difference between the percent change in LV systolic function in Group I and Group III (P-value = 0.854, 0.152 respectively) but there was statistically significant difference between the percent change in LV systolic function in Group II (P-value=0.031). Conclusion: The best way for treatment of acute STEMI patients, is a primary PCI the most significant predictive methods are recovery of EF% and reduction of BNP, however pharmacoinavsive strategy like PCI strategy has good follow up prognosis and better than thrombolytic alone therapy. [ABSTRACT FROM AUTHOR]

There is limited information on the comparative results of using different thrombolytic drugs for pharmacoinvasive reperfusion in acute ST-segment elevation myocardial infarction (STEMI). There is special interest in comparing the efficacy of fibrin-selective and fibrin-non-selective thrombolytics.Aim. To study the prevalence of major adverse cardiovascular events and the status of patients who had STEMI and pharmacoinvasive reperfusion a year ago, depending on the choice of thrombolytic drug.Material and methods. 240 STEMI-patients undergoing pharmacoinvasive reperfusion (reference event) were divided into 4 groups depending on the choice of the thrombolytic drug (alteplase [group 1], teneteplase [group 2], fortetelizin [group 3], streptokinase [group 4]) as well as into 2 groups depending on the fibrin-specificity of thrombolytics. One year after the reference event the prevalence of major cardiovascular events (death, repeated myocardial infarction, stroke, repeated revascularization of the target vessel, and their combination) was assessed. Data of echocardiography and 24-hour ECG monitoring, indicis of rating scale of clinical state in patients with heart failure (RSCS, Mareev V.Y, 2000), results of determination of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) and of six-minute walk test were also analyzed.Results. One year after the reference event, patients who received fibrin-selective thrombolytics (groups 1,2, 3) compared with patients treated with fibrin-non-selective drug (group 4) had a higher left ventricular ejection fraction (49.8±7.4% vs 47,4±6.8%; p=0.048), lower index of impaired local contractility (1.19 [1.06; 1.38] vs 1.25 [1.175; 1.5], p=0.029), an end-diastolic volume (1 39.1 ±28.6 ml vs 148.7±23.9 ml; p=0.027), the size of the left atrium (39.0±4.6 mm vs 41.1 ±3.1 mm, p=0.007 ), and insignificantly lower prevalence of atrial fibrillation (1.5% vs 6.7%, p=0.068). They also showed a lower prevalence of supraventricular tachycardia (4.5% vs 13.3%, p=0.049) and ventricular extrasystoles (54.5% vs 76.7%, p=0.022) as well as the daily number of ventricular extrasystoles (4.5 [0; 32.0] vs 34, 0 [2.25; 80.25], p=0.001) with more favorable gradations and indicators of heart rate variability. Statistically significantly lower NT-proBNP level (148 [1 20; 208.5] pg/ml vs 241 [189; 287] pg/ml; p=0.000) and chronic heart failure manifestation according to RSCS (p=0.033), as well as a longer distance in the six-minute walk test (p=0.000) were found in patients treated with fibrin-selective drugs. Statistically significant differences between groups 1, 2, 3 for the study period were not found. Significant differences in the prevalence of hard clinical endpoints (death, repeated myocardial infarction, stroke, repeated revascularization of the target artery) were not found in all groups.Conclusion. More favorable clinical, laboratory and instrumental parameters were found one year after STEMI and pharmacoinvasive reperfusion with fibrin-specific thrombolytic agents as compared with fibrin-non-specific thrombolytic. All groups had no statistically significant differences in the effect on hard clinical endpoints during the entire observation period.

Primary percutaneous coronary intervention (PPCI), the preferred reperfusion strategy for all acute ST‐segment elevation myocardial infarction (STEMI) patients, is not universally available in clinical practice. Pharmacoinvasive strategy has been proposed as a therapeutic option in patients with STEMI when timely PPCI is not feasible. However, pharmacoinvasive strategy has potential delay between clinical patency and complete myocardial perfusion. The optimal reperfusion strategy for STEMI patients with anticipated PPCI delay according to current practice is uncertain. OPTIMAL‐REPERFUSION is an investigator‐initiated, prospective, multicenter, randomized, open‐label, superiority trial with blinded evaluation of outcomes. A total of 632 STEMI patients presenting within 6 hours after symptom onset and with an expected time of first medical contact to percutaneous coronary intervention (PCI) ≥120 minute will be randomized to a reduced‐dose facilitated PCI strategy (reduced‐dose fibrinolysis combined with simultaneous transfer for immediate invasive therapy with a time interval between fibrinolysis to PCI < 3 hours) or to standard pharmacoinvasive treatment. The primary endpoint is the composite of death, reinfarction, refractory ischemia, congestive heart failure, or cardiogenic shock at 30‐days. Enrollment of the first patient is planned in March 2021. The recruitment is anticipated to last for 12 to 18 months and to complete in September 2023 with 1 year follow‐up. The OPTIMAL‐REPERFUSION trial will help determine whether reduced‐dose facilitated PCI strategy improves clinical outcomes in patients with STEMI and anticipated PPCI delay. This study is registered with the ClinicalTrials.gov (NCT04752345). [ABSTRACT FROM AUTHOR]

Background: Pharmacoinvasive strategy (PIS) is the alternative approach to primary percutaneous coronary intervention (PCI) if PCI capable center isn’t available especially in the developing countries. Our objective of the current study was to investigate the incidence of contrast induced nephropathy (CIN), the occurrence of no reflow phenomenon and major adverse cardiac events (MACE) in patients with decreased estimated glomerular filtration rate (e-GFR) after successful fibrinolytic therapy in order to assess the benefit from very early PCI strategy (within 3–12 hours) or early PCI strategy (within 12–24 hours). Methods: This randomized clinical trial included 420 patients with STEMI. All participants were classified randomly into two groups according to the time of intervention; Group I patients were subjected to very early PCI (within 3–12 hours) and Group II patients were subjected to early PCI (within 12–24 hours) after receiving successful fibrinolytic therapy. Results: The incidence of CIN in Group I was slightly higher than Group II (23 patients [10.7%] versus 19 patients [9.3%]) respectively, with no statistically significant difference between the two groups (P value = 0.625). The incidence of no-reflow phenomenon (TIMI 0–2 flow) after the procedure was higher in Group II, while TIMI 3 flow (normal flow) was significantly higher in Group I than Group II (184 [85.6%] vs. 153 [74.6%], respectively) with P value = 0.044. There was no statistically significant difference between the two groups regarding mortality and MACE. Conclusion: The incidence of CIN was nearly equal in very early PCI (within 3–12 hours) versus early PCI (within 12–24 hours); however, the incidence of no-reflow phenomenon was significantly higher in patients subjected to early PCI (within 12–24 hours).

Aim. Evaluate the one­year results and clinical outcomes of a multi­center randomized clinical trial FRIDOM1.Material and methods. The study FRIDOM1 was conducted in 11 clinical centers of the Russian Federation in the period 2014­2016. The study included 382 patients with acute ST­elevated myocardial infarction (STEMI), who were randomly divided into the Fortelyzin® and Metalyse®. Thrombolysis was accompanied by anticoagulant and dual antiplatelet therapy followed by percutaneous coronary intervention (PCI). One­year patient status, all­cause mortality, including cardiovascular diseases (CVD), hospitalization, and one­year survival were assessed by telephone contact.Results. The one­year patient status was determined in 186 out of 191 (97,4%) in the Fortelyzin® group and in 185 out of 191 (96,9%) patients in the Metalyse® group. One­year all­cause mortality was 5,9% and 6,5% in the Fortelyzin® and Metalyse® groups, respectively (p=0,83; OR 0,91; 95% CI — 0,42­1,98). One­year mortality from CVD in the Fortelyzin® group is 5,4%, in the Metalyse® group — 6,5% (p=0,67; OR 0,83; 95% CI — 0,37­1,83). All­cause mortality between 30 days and 1 year in the Fortelyzin® group was in 2,2% of patients, CVD — in 1,6%, in the group of Metalise® mortality was in 2,7% of patients (all — CVD). One­year survival was 94,1% and 93,5% in the Fortelyzin® and Metalyse® groups, respectively.Conclusion. The one­year results of the FRIDOM1 study showed the efficacy and safety of a single bolus administration of Fortelyzin® as part of a pharmaco­invasive strategy for treating patients with STEMI, as well as clinical outcomes that are comparable with Metalyse®, including high survival rates and low CVD mortality.

The lethality of patients with acute myocardial infarction with ST-segment elevation (STEMI) depends on many factors. In conditions of timely transportation of the patient to the center of percutaneous coronary intervention one of these factors is the severity of the coronary bed lesion. In clinical practice, the most common method of assessing such lesions is the SYNTAX Score scale.Aim. To study the impact of the assessment by angiographic SYNTAX Score scale on in-hospital complications and lethality in patients with STEMI.Material and methods. The single-center observational retrospective study was performed. The medical data of 816 cases of treatment of patients with STEMI in the first 6 hours from the onset of symptoms were analyzed. All patients underwent reperfusion therapy (primary percutaneous coronary intervention or pharmacoinvasive strategy (FIS)) with assessment of the SYNTAX Score index prior to intervention. The main group (SYNTAX Score ≤22 points) and the comparison group (SYNTAX Score index >22 points) were comparable in terms of clinical characteristics and time delays.Results. An increase in the SYNTAX Score more than 22 points was an independent predictor of hospital complications and lethality (4.9% for SYNTAX Score ≤22 points and 21.9% – for >22 points). The group with a high SYNTAX index was older, had a higher proportion of smokers (46.8% vs 36.1%, p=0.015) and patients with myocardial infarction history (38.5% vs 20.6%, p

Background The 2017 ESC guideline on patients with ST-segment elevation myocardial infarction (STEMI) provides guidance regarding the optimal management of these patients. Transient atrioventricular (AV) block is a relatively common complication of inferior STEMI and its management is also addressed in the guidelines. Case summary A 64-year-old gentleman with multiple cardiovascular risk factors presented to the emergency department with a history of ischaemic type chest pain and evidence of inferior ST-segment elevation on his electrocardiogram (ECG). First-degree AV block was noted on his initial ECG. He was given thrombolytic therapy as part of a pharmacoinvasive strategy of reperfusion. He, however, failed fibrinolytic therapy, and emergency angiography revealed critical disease of the right coronary artery which was successfully stented. Subsequent to reperfusion, he developed complete AV block without evidence of re-infarction, which was managed conservatively with successful resolution of the block after 7 days of expectant management with temporary transvenous pacing. Discussion We highlight some of the important management principles from the ESC guideline of STEMI including timing and the management of AV block in these patients. In addition, we highlight the role of a pharmacoinvasive strategy for reperfusion where timeous primary percutaneous coronary intervention cannot be performed. The usefulness of such a strategy within the COVID-19 era is also emphasized. [ABSTRACT FROM AUTHOR]

Although primary percutaneous coronary intervention (pPCI) is the treatment of choice in ST-elevation myocardial infarction (STEMI), challenges may arise in accessing this intervention for certain geodemographic groups. Pharmacoinvasive strategy (PIs) has demonstrated comparable outcomes when delays in pPCI are anticipated, but real-world data on long-term outcomes are limited. The aim of the present study was to compare long-term outcomes among real-world patients with STEMI who underwent either PIs or pPCI. This was a prospective registry including patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary objective was cardiovascular mortality at 12 months according to the reperfusion strategy (pPCI vs PIs) and major cardiovascular events (cardiogenic shock, recurrent myocardial infarction, and congestive heart failure), and Bleeding Academic Research Consortium type 3 to 5 bleeding events were also evaluated. A total of 799 patients with STEMI were included; 49.1% underwent pPCI and 50.9% received PIs. Patients in the PIs group presented with more heart failure on admission (Killip-Kimbal >I 48.1 vs 39.7, p = 0.02) and had a lower proportion of pre-existing heart failure (0.2% vs 1.8%, p = 0.02) and atrial fibrillation (0.25% vs 1.2%, p = 0.02). No statistically significant difference was observed in cardiovascular mortality at the 12-month follow-up (hazard ratio for PIs 0.74, 95% confidence interval 0.42 to 1.30, log-rank p = 0.30) according to the reperfusion strategy used. The composite of major cardiovascular events (hazard ratio for PIs 0.98, 95% confidence interval 0.75 to 1.29, p = 0.92) and Bleeding Academic Research Consortium type 3 to 5 bleeding rates were also comparable. A low socioeconomic status, Killip-Kimball >2, age >60 years, and admission creatinine >2.0 mg/100 ml were predictors of the composite end point after multivariate analysis. In conclusion, this prospective real-world registry provides additional support that long-term major cardiovascular outcomes and bleeding are not different between patients who underwent PIs versus primary PCI., Competing Interests: Declaration of competing interest Dr. Arias-Mendoza reports a relation with Boehringer Ingelheim, Novartis, Sanofi Aventis, and Novo Nordisk that includes speaking fees. Dr. Gopar-Nieto reports a relation with Novartis that includes speaking fees. Dr. Briseño-De la Cruz reports for a relation with Astra Zeneca, Boehringer Ingelheim, and Boston Scientific that includes speaking fees. Dr. Araiza-Garaygordobil reports a relation with Abbott, Asofarma, Astra Zeneca, Boehringer Ingelheim (Ingelheim, Germany), Eurofarma, Medix, Novartis, Silanes, and Servier that includes speaking fees. He also reports relation with Novartis that includes advisory board activities for Silanes and Servier and Research grants. The remaining authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Pharmacoinvasive strategy (PIS) is the alternative approach to primary percutaneous coronary intervention (PCI) if PCI capable center isn't available especially in the developing countries. Our objective of the current study was to investigate the incidence of contrast induced nephropathy (CIN), the occurrence of no reflow phenomenon and major adverse cardiac events (MACE) in patients with decreased estimated glomerular filtration rate (e-GFR) after successful fibrinolytic therapy in order to assess the benefit from very early PCI strategy (within 3-12 hours) or early PCI strategy (within 12-24 hours). Methods: This randomized clinical trial included 420 patients with STEMI. All participants were classified randomly into two groups according to the time of intervention; Group I patients were subjected to very early PCI (within 3-12 hours) and Group II patients were subjected to early PCI (within 12-24 hours) after receiving successful fibrinolytic therapy. Results: The incidence of CIN in Group I was slightly higher than Group II (23 patients [10.7%] versus 19 patients [9.3%]) respectively, with no statistically significant difference between the two groups (P value = 0.625). The incidence of no-reflow phenomenon (TIMI 0-2 flow) after the procedure was higher in Group II, while TIMI 3 flow (normal flow) was significantly higher in Group I than Group II (184 [85.6%] vs. 153 [74.6%], respectively) with P value = 0.044. There was no statistically significant difference between the two groups regarding mortality and MACE. Conclusion: The incidence of CIN was nearly equal in very early PCI (within 3-12 hours) versus early PCI (within 12-24 hours); however, the incidence of no-reflow phenomenon was significantly higher in patients subjected to early PCI (within 12-24 hours). [ABSTRACT FROM AUTHOR]

Gender differences can significantly affect mortality in ST-segment elevation myocardial infarction (STEMI) in real practice. Aim. To evaluate the effect of gender on mortality in STEMI. Material and methods. Outcomes of in-hospital stage of treatment of 553 men (67.7%) and 263 women (32.3%) were analyzed in single-center retrospective study. Primary percutaneous coronary intervention (pPCI) and pharmacoinvasive strategy (PIS) were used in 160 (60.8%) and 103 (39.2%) women, respectively, as well as in 295 (53.3%) and 258 (46.7%) men, respectively. Patients with time ″primary medical contact (PMC) – balloon″ less than 60 min and ″symptom - PMC″ more than 6 hours were excluded. The majority of patients were in a time interval ″PMC - balloon″ about 120 minutes. Results. Mortality in women was significantly higher than this in men regardless of the reperfusion strategy – 15.3% in whole (18.1% at pPCI and 10.9% at PIS), and 3.1% in whole (5.1% at pPCI and 0.8% at FIS), respectively (p

Presented case report demonstrates the efficacy and safety of hospital use of thrombolytic agent Fortelizin in pharmaco-invasive strategy for the treatment of a patient with acute myocardial infarction and with a long history of ischemic heart disease and long-term dynamics of the verified angiographic progression of coronary atherosclerosis. Hospital thrombolytic therapy with Fortelizin was vital alternative in case of a substantial time delay in mechanical reperfusion of the myocardium.

Background: A pharmacoinvasive strategy may alleviate the logistical and geographical barriers in timely reperfusion of ST-segment elevation myocardial infarction (STEMI), especially in a developing country like India. Aim: To assess the safety and efficacy of pharmacoinvasive strategy versus primary PCI in STEMI patients at 2 years. Methods: Patients enrolled in STEPP-AMI, an observational, multicenter, prospective study of 200 patients presenting with STEMI, were followed up for 2 years. Group ‘A’ comprised of patients with pharmacoinvasive strategy (n = 45), and patients who underwent primary PCI (n = 155) formed group ‘B’. Primary endpoint was composite of death, cardiogenic shock, reinfarction, repeat revascularization of the culprit artery, or congestive heart failure at 30 days, with follow-up till 2 years. Results: The primary endpoint occurred in 11.1% and 17.8% in group A and in 3.9% and 13.6% in group B, at 30 days and 2 years, respectively (p = 0.07, RR = 2.87; 95% CI: 0.92–8.97 at 30 days and p = 0.47, RR = 1.31; 95% CI: 0.62–2.76). There was no difference in bleeding risk between groups, 2.2% in group A and 0.6% in group B (‘p’ = 0.4). The infarct-related artery patency varied at angiogram; it was 82.2% in arm A and 22.6% in arm B (‘p’

Background: The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain., Objective: To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy., Material and Methods: Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were classified according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Epicardial blood flow was assessed using the TIMI grading system after reperfusion., Results: A total of 935 patients were included; 85.6% were males and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235)., Conclusions: A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI)., (Copyright: © 2024 Permanyer.)

Myocardial infarction significantly contributes to mortality rates in patients with chronic obstructive pulmonary disease (COPD). The influence of COPD on the course of acute ST-segment elevation myocardial infarction (STEMI) is controversial.Aim. To evaluate characteristics of coronary artery lesions and cardiovascular complications in STEMI patients with and without COPD depending on a reperfusion treatment method during in-hospital stay.Material and methods. A total of 1112 cases of STEMI treatment within the first 6 hours of the symptoms onset were analyzed. All of these patients have undergone reperfusion treatment: primary percutaneous coronary intervention (PPCI) or pharmacoinvasive strategy (PIS) methods. All the patients were divided into two groups: patients without COPD (952 persons; 83.2%) and those with COPD (160 patients; 16.8%). COPD impact on in-hospital course of STEMI was assessed.Results. The presence of COPD had no influence on STEMI in-hospital mortality. Mortality rates in patients with COPD (12 subjects; 7.5%) and without COPD (83 subjects; 8.7%) did not differ significantly (p=0.2). The study has demonstrated the significant influence of COPD on the patients’ baseline characteristics and treatment results, which can have an impact on long-term prognosis. According to our data COPD presence was associated with more severe coronary artery lesions in both PPCI and PIS subgroups (p

BackgroundThe effectiveness of radial access (RA) in ST‐elevation myocardial infarction (STEMI) has been predominantly established in primary percutaneous coronary intervention (pPCI) with limited exploration of this issue in the early postfibrinolytic patient. The purpose of this study was to compare the effectiveness and safety of RA versus femoral (FA) access in STEMI undergoing either a pharmacoinvasive (PI) strategy or pPCI. Methods and ResultsWithin STrategic Reperfusion Early After Myocardial Infarction (STREAM), we evaluated the relationship between arterial access site and primary outcome (30‐day composite of death, shock, congestive heart failure, or reinfarction) and major bleeding according to the treatment strategy received. A total of 1820 STEMI patients were included: 895 PI (49.2%; rescue PCI [n=379; 42.3%], scheduled PCI [n=516; 57.7%]) and 925 pPCI (50.8%). Irrespective of treatment strategy, there was comparable utilization of either access site (FA: PI 53.4% and pPCI 57.6%). FA STEMI patients were younger, had lower presenting systolic blood pressure, lesser Thrombolysis In Myocardial Infarction risk, and more ∑ST‐elevation at baseline. The primary composite endpoint occurred in 8.9% RA versus 15.7% FA patients (P

The review discusses various reperfusion strategies in patients with acute myocardial infarction with ST segment elevation (STEMI), based on the evidence from international clinical trials. The modern views on real-world invasive and conservative strategies of STEMI management in European countries are presented. The key factor for patients’ survival is the timing, not the method of reperfusion. The strategy of primary percutaneous coronary intervention (PCI) may fail to reduce mortality, if the door-to-balloon time is over 60 minutes, compared to immediate thrombolytic therapy (TLT). PCI is more effective than TLT only if the time difference (door-to-balloon vs. door-to-needle) is under 2 hours. The choice of reperfusion method should be based on the patient’s risk level. Primary PCI has limitations, since this method is not widely accessible, requires specially trained staff and special equipment. Early TLT is an acceptable standard method in STEMI management, highly applicable for the Russian clinical practice. However, in patients already treated with TLT, pharmaco-invasive strategy could be the method of choice. The description of thrombolytic drugs is focussed on the agents of II and III generations – alteplase (Actilyse®) and tenecteplase (Metalyse®), respectively. Before the introduction of Metalyse®, continuous infusion of Actilyse® was regarded as the gold standard of pharmacological reperfusion therapy. Recently, it has been shown that single-bolus Metalyse® therapy is as effective as continuous Actilyse® infusion, but with better safety profile. Pre-hospital TLT with single-bolus Metalyse® therapy (5-10 seconds) provides a unique clinical opportunity for early STEMI management and maximal myocardial rescue.

Objectives This study investigated the safety and efficacy of a pharmacoinvasive strategy compared with a primary percutaneous coronary intervention (PCI) strategy for ST-segment elevation myocardial infarction (STEMI) in the context of a real-world system. Background Primary PCI continues to be the optimal reperfusion therapy; however, in areas where PCI centers are not readily available, a pharmacoinvasive strategy has been proposed. Methods The University of Ottawa Heart Institute regional STEMI system provides a primary PCI strategy for patients presenting within a 90-km radius from the PCI center, and a pharmacoinvasive strategy for patients outside this limit. We included all confirmed STEMI patients between April 2009 and May 2011. The primary efficacy outcome was a composite of mortality, reinfarction, or stroke and the primary safety outcome was major bleeding. Results We identified 236 and 980 consecutive patients enrolled in pharmacoinvasive and primary PCI strategies, respectively. The median door-to-needle time was 31 min in the pharmacoinvasive group and the median door-to-balloon time was 95 min in the primary PCI group. In a multivariable model, there was no significant difference in the primary efficacy outcome (odds ratio: 1.54; p = 0.21); however, the propensity for more bleeding with a pharmacoinvasive strategy approached statistical significance (odds ratio: 2.02; p = 0.08). Conclusions Within the context of a STEMI system, a pharmacoinvasive strategy was associated with similar rates of the composite of mortality, reinfarction, or stroke as compared with a primary PCI strategy; however, there was a propensity for more bleeding with a pharmacoinvasive strategy. [ABSTRACT FROM AUTHOR]

A well-organized network for primary percutaneous coronary intervention (pPCI) is of paramount importance in providing optimal healthcare for patients with acute coronary syndrome (ACS). Organizing a pPCI network is a lengthy and logistically complex task. The purpose of gathering, analyzing, and sharing data on the functioning of the network is to improve the system. Monitoring everyday work and gathering, analyzing, and sharing data are the key elements of continuous improvement. This article describes the efforts to develop a quality monitoring program for the treatment of patients with ACS in western Slavonia - a region in Croatia. We also explain the diagnostic, treatment, and destination protocols used and the types of data we will monitor as indicators of quality and comprehensiveness of care for patients with ACS. [ABSTRACT FROM AUTHOR]

Management of STEMI patients consist of initial recognition and diagnosis, early routine medication, and reperfusion therapy. Primary PCI has been set as default strategy for STEMI reperfusion in PCI-capable hospital. Unfortunately, only few STEMI patients can undergo primary PCI as reperfusion therapy, because the number of hospital with invasive capability is still low in many countries, including Indonesia. Because time is critical in reperfusion therapy, the emergency physicians in non-PCI capable hospital have to decide to hold or refer STEMI patients to a hospital with invasive capability. The reperfusion therapy options for STEMI patient presentingto a non-PCI capable hospital are fibrinolytic therapy, or refer to PCI-capable hospital, or both (pharmacoinvasive strategy). This review tried to summarize the evidences as a consideration in choosing the best reperfusion strategy for STEMI patients presenting to non-PCI capable hospital.

Background: ST-elevation myocardial infarction (STEMI) refers to a clinical syndrome that features symptoms of myocardial ischemia with consequent ST-elevation on electrocardiography and an associated rise in cardiac biomarkers. Rapid restoration of brisk flow in the coronary vasculature is critical in reducing mortality and morbidity. In patients with STEMI who could not receive primary percutaneous coronary intervention (PCI) on time, pharmacoinvasive strategy (thrombolysis followed by timely PCI within 3-24 h of its initiation) is an effective option., Aim: To analyze the role of delayed pharmacoinvasive strategy in the window period of 24-72 h after thrombolysis., Methods: This was a physician-initiated, single-center prospective registry between January 2017 and July 2017 which enrolled 337 acute STEMI patients with partially occluded coronary arteries. Patients received routine pharmacoinvasive therapy (PCI within 3-24 h of thrombolysis) in one group and delayed pharmacoinvasive therapy (PCI within 24-72 h of thrombolysis) in another group. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) within 30 d of the procedure. The secondary endpoints included major bleeding as defined by Bleeding Academic Research Consortium classification, angina, and dyspnea within 30 d., Results: The mean age in the two groups was comparable (55.1 ± 10.1 years vs 54.2 ± 10.5 years, P = 0.426). Diabetes was present among 20.2% and 22.1% of patients in the routine and delayed groups, respectively. Smoking rate was 54.6% and 55.8% in the routine and delayed groups, respectively. Thrombolysis was initiated within 6 h of onset of symptoms in both groups ( P = 0.125). The mean time from thrombolysis to PCI in the routine and delayed groups was 16.9 ± 5.3 h and 44.1 ± 14.7 h, respectively. No significant difference was found for the occurrence of measured clinical outcomes in the two groups within 30 d (8.7% vs 12.9%, P = 0.152). Univariate analysis of demographic characteristics and risk factors for patients who reported MACCE in the two groups did not demonstrate any significant correlation. Secondary endpoints such as angina, dyspnea, and major bleeding were non-significantly different between the two groups., Conclusion: Delayed PCI pharmacoinvasive strategy in a critical diseased but not completely occluded artery beyond 24 h in patients who have been timely thrombolyzed seems a reasonable strategy., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Pharmacoinvasive treatment is an acceptable alternative for patients with ST-segment elevation myocardial infarction (STEMI) in developing countries. The present study evaluated the influence of gender on the risks of death and major adverse cardiovascular events (MACE) in this population. Seven municipal emergency rooms and the Emergency Mobile Healthcare Service in São Paulo treated STEMI patients with tenecteplase. The patients were subsequently transferred to a tertiary teaching hospital for early (<24 h) coronary angiography. A total of 469 patients were evaluated [329 men (70.1 %)]. Compared to men, women had more advanced age (60.2 ± 12.3 vs. 56.5 ± 11 years; p = 0.002); lower body mass index (BMI; 25.85 ± 5.07 vs. 27.04 ± 4.26 kg/m; p = 0.009); higher rates of hypertension (70.7 vs. 59.3 %, p = 0.02); higher incidence of hypothyroidism (20.0 vs. 5.5 %; p < 0.001), chronic renal failure (10.0 vs. 8.8 %; p = 0.68), peripheral vascular disease (PVD; 19.3 vs. 4.3 %; p = 0.03), and previous history of stroke (6.4 vs. 1.3 %; p = 0.13); and higher thrombolysis in myocardial infarction risk scores (40.0 vs. 23.7 %; p < 0.001). The overall in-hospital mortality and MACE rates for women versus men were 9.3 versus 4.9 % ( p = 0.07) and 12.9 versus 7.9 % ( p = 0.09), respectively. By multivariate analysis, diabetes (OR 4.15; 95 % CI 1.86-9.25; p = 0.001), previous stroke (OR 4.81; 95 % CI 1.49-15.52; p = 0.009), and hypothyroidism (OR 3.75; 95 % CI 1.44-9.81; p = 0.007), were independent predictors of mortality, whereas diabetes (OR 2.05; 95 % CI 1.03-4.06; p = 0.04), PVD (OR 2.38; 95 % CI 0.88-6.43; p = 0.08), were predictors of MACE. In STEMI patients undergoing pharmacoinvasive strategy, mortality and MACE rates were twice as high in women; however, this was due to a higher prevalence of risk factors and not gender itself. [ABSTRACT FROM AUTHOR]

Over the recent years it has been clearly demonstrated that reperfusion by primary coronary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals without the capacity of performing primary angioplasty, reperfusion with on-site thrombolysis or transportation of the patient to another institution for primary percutaneous coronary intervention (PCI) within a tight timeframe are the alternative options. For the latter strategy, an organized network of centers is needed to rapidly transfer STEMI patients for primary PCI. Although transferring STEMI patients for primary PCI is superior reperfusion therapy in comparison to on-site thrombolysis, there are concerns, regarding time delays of transfer in daily practice, which is a major drawback of this therapeutic strategy as delays of >120 minutes from first medical contact to primary PCI negate the advantage of primary PCI over thrombolysis. The narrow time interval (<90-120 min) that is mandatory for the superiority of primary PCI, could be extended if a pharmacoinvasive strategy (fibrinolysis followed by routine "early" angioplasty of the culprit artery) was chosen. Convincing results from trials such as TRANSFER-AMI, FAST-MI, GRACIA-2, WEST-MI, CARESS-AMI, NORDISTEMI and STREAM indicated that combined use of thrombolysis followed by PCI after >3 hours to 6-12 hours in order to neutralize the thrombolysis associated complications of PCI and allow full action of antiplatelet and antithrombotic agents, had comparable efficacy in comparison to primary PCI regarding early and 1-year survival. This appears to be an effective alternative option for the treatment of STEMI patients, at least for those hospitals wherebimmediate PCI is unavailable, an issue which is particularly relevant for patients suffering a STEMI on remote areas or islands. [ABSTRACT FROM AUTHOR]

ST-elevation myocardial infarction (STEMI) is related to acute occlusion of a coronary artery by a fibrin-rich thrombus. Early reperfusion in STEMI reduces infarct size and improves prognosis. Acute reperfusion may be achieved with percutaneous coronary intervention (PCI) and/or fibrinolytic agents. When performed in a timely manner, primary PCI is the preferred method of reperfusion; however, due to logistic reasons, including lack of PCI-capable hospitals and delay in the first medical contact-to-balloon time, this simplified approach lacks universal applicability. Due to clinical efficacy and the ease of administration, fibrinolysis is still an important reperfusion modality in patients with STEMI who cannot have primary PCI within guideline-recommended time. This review focuses on the role of fibrinolysis in patients with STEMI. [ABSTRACT FROM AUTHOR]

Effective, early and rapid reperfusion therapy is the most important goal in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI). Timely performed primary percutaneous coronary intervention (pPCI) is undoubtedly the strategy of choice in the treatment of STEMI and in the last decade pPCI has replaced fibrinolytic therapy as a way revascularization strategy. Many clinical studies have shown that patients treated with fibrinolysis should be routinely moved to the invasive cardiology center for elective percutaneous coronary intervention (PCI) within 24 hours and that this early invasive strategy leads to a stabilization of the target lesion and lowers the incidence of recurrent ischemia. The latest European Society of Cardiology Guidelines for the management of patients with STEMI award the Class I indication to the pharmacoinvasive strategy. This review article presents the most important clinical research on pharmacoinvasive strategy and importance of this method of treatment of STEMI. This method of reperfusion leads to a significant reduction in reinfarction and recurrent ischemia without increased risk of bleeding and implementing this strategy in regional protocols for the management of patients with STEMI would increase the number of patients who are to receive proper and timely reperfusion therapy. [ABSTRACT FROM AUTHOR]

Croatian Primary Percutaneous Intervention Network is an internationally recognized system of good organization of urgent treatment of cardiac patients. In everyday clinical practice, we have witnessed that the time required for the organization of primary percutaneous coronary intervention (pPCI), which represents the best way of reperfusion therapy in the treatment of patients with acute ST-segment elevation myocardial infarction is often too long and associated with unacceptably long delays. Pharmacoinvasive strategy encompasses a selective use of fibrinolytic therapy to be followed by prompt transportation of patients to a center capable of undertaking percutanous coronary intervention and organizing invasive treatment within 3-24 hours. Considering the organizational difficulties caused by the incapability of undertaking prompt pPCI, the application of pharmacoinvasive approach would increase the number of patients that would be provided proper and timely reperfusion therapy. Here are some practical recommendations for implementation of the pharmacoinvasive strategy in everyday clinical practice and protocol of the local organization of the pPCI network in the General Hospital "Dr. Josip Benčević" in Slavonski Brod, Croatia. [ABSTRACT FROM AUTHOR]

Background: The de Winter's electrocardiogram (ECG) pattern signifying proximal left anterior descending (LAD) artery occlusion was first described in 2008. The ECG changes were thought to be static and mechanisms for this were suggested. In addition, the optimal management of these patients was reported to be via a primary percutaneous coronary intervention (PCI) strategy., Case Summary: Case 1 : A 48-year-old gentleman presented with a 2-h history of ischaemic chest pain with initial de Winter's pattern on ECG. This progressed to anterior ST-elevation myocardial infarction (STEMI) complicated by ventricular fibrillation. Emergency angiography revealed a mid-vessel LAD occlusion which was successfully reperfused. Case 2 : A 34-year-old female presented with a 2-h history of ischaemic chest pain with initial ECG showing a de Winter's pattern. Due to concerns of performing PCI timeously, a pharmacoinvasive strategy of reperfusion was adopted with resolution of the de Winter's pattern. Urgent angiography revealed a proximal LAD lesion which was successfully stented., Discussion: The two cases highlight that the de Winter's pattern may in fact not be static, but rather lie along the continuum of ischaemia and may evolve into STEMI. In addition, we provide further evidence that if primary PCI cannot be offered in a timeous manner, thrombolytic therapy may be considered in such patients. The de Winter's pattern remains a high-risk ECG pattern that requires early recognition and intervention., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

The aim of this study was to investigate the efficacy and safety of percutaneous coronary intervention (PCI) in elderly patients with acute myocardial infarction after thrombolytic reperfusion with indirect reperfusion signs. A total of 96 patients aged 75 years and over with acute myocardial infarction and successful thrombolysis (reduction of ST segment elevation 90 min after thrombolysis) were included in this study. Thirty patients (31%) were selected for delayed PCI. Stent implantation was performed in 70% of cases (21 patients). The bleeding rates did not differ between groups of delayed PCI and conservative therapy. The rate of contrast-induced nephropathy was 6,7%. The rates of recurrent myocardial infarction (ReMI) and lethality did not differ between groups of delayed PCI and conservative therapy. The rates of ReMI after discharge from hospital and the lethality rates within one year did not differ. Then, the patients were assigned to two groups: stented group (n=21) and non-stented group (n=75). The ReMI and lethality rates did not differ between these groups in-hospitally and within one year, but the rate of composite outcome (ReMI + lethality) within one year was lower in stented group: 33,3% vs 41,3% (p=0,039).

Effective, early and rapid reperfusion therapy is the most important goal in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI). Timely performed primary percutaneous coronary intervention (pPCI) is undoubtedly the strategy of choice in the treatment of STEMI and in the last decade pPCI has replaced fibrinolytic therapy as a revascularization strategy. Many clinical studies have shown that patients treated with fibrinolysis should be routinely moved to the invasive cardiology center for elective percutaneous coronary intervention (PCI) within 24 hours and that this early invasive strategy leads to a stabilization of the target lesion and lowers incidence of recurrent ischemia. The latest European Society of Cardiology Guidelines for the management of patients with STEMI award the Class I indication to the pharmacoinvasive strategy. This presentation presents the most important clinical research on pharmacoinvasive strategy and importance of this method of treatment of STEMI. This method of reperfusion leads to a significant reduction in reinfarction and recurrent ischemia without increased risk of bleeding and implementing this strategy in regional protocols for management of patients with STEMI would increase the number of patients who are to receive proper and timely reperfusion therapy. [ABSTRACT FROM AUTHOR]

Objective: Primary Percutaneous Coronary Intervention (PCI) is the treatment of choice for ST-segment Elevation Myocardial Infarction (STEMI) if performed within 90 minutes from first medical contact. However, primary PCI is only available for less than 25% of patients with STEMI. Early PCI or Pharmaco-invasive strategy has evolved from facilitated PCI but with more delayed timing from thrombolysis to PCI., Aim: Assess the safety and effectiveness of Early PCI., Patients and Method: We reviewed the data of the available therapy options for patients with STEMI. Then we performed a meta-analysis for all randomized controlled trials of early PCI versus standard therapy., Results: Five studies fulfilled our inclusion criteria. Our meta-analysis showed improved cardiovascular events with early PCI compared to standard therapy (odd ratio of 0.54; 95% Confidence interval 0.47-0.7, p<0.001). There were no significant bleeding complications when doing early PCI 4 to 24 hours after successful thrombolysis., Conclusion: Early PCI should be done to all STEMI patients within 24 hours after successful thrombolysis.