OBJECTIVE: System delay is associated with mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). However, the influence of patient delay has been relatively overlooked. We aimed to evaluate the influence of patient and system delays on STEMI patients undergoing primary PCI in China.
METHODS: STEMI patients registered at the Nationwide Chinese Cardiovascular Association Database-Chest Pain Center from January 2017 to September 2021 were screened. The exposures were total ischemic time (TIT), system delay and patient delay. The primary outcome was in-hospital mortality.
RESULTS: Among 458,260 patients from 2,529 centers, median TIT, system delay and patient delay were 4.1, 1.5 and 2.1 hours, respectively. The adjusted odds ratio of in-hospital mortality increased by 2.2% (odds ratio [OR], 1.022, 95% confidence interval [CI], 1.017-1.027), 2.3% (1.023, 1.006-1.040) and 2.2% (1.022, 1.017-1.027) for every one-hour increase in TIT, system delay and patient delay, respectively.
CONCLUSIONS: Patient delay demonstrated a comparable impact to system delay on in-hospital mortality among STEMI patients undergoing primary PCI. Widespread primary PCI-capable center, improved awareness about myocardial infarction and regional transfer system are essential to shorten patient delay.

BACKGROUND: The effectiveness of complete revascularization is well established in patients with ST-segment elevation myocardial infarction (STEMI), but it is less investigated in those with non-ST-segment elevation myocardial infarction (NSTEMI).
OBJECTIVE: This study aimed to assess whether complete revascularization, compared with culprit-only revascularization, was associated with consistent outcomes in older patients with STEMI and NSTEMI.
METHODS: In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, 1,445 older patients with myocardial infarction (MI) were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs n = 253 complete) and NSTEMI (n = 469 culprit-only vs n = 467 complete). The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome included a composite of cardiovascular death or MI at 1 year.
RESULTS: In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only vs 41 (16.2%) STEMI patients of the complete group (HR: 0.75; 95% CI: 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only vs 72 (15.4%) NSTEMI patients of the complete group (HR: 0.71; 95% CI: 0.53-0.97), with negative interaction testing (P for interaction, 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (P for interaction, 0.654).
CONCLUSIONS: Physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI. (FIRE [Functional Assessment in Elderly MI Patients With Multivessel Disease]; NCT03772743).

UNASSIGNED: The optimal timing for nonculprit vascular reconstruction surgery in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still controversial. Our aim was to explore the optimal intervention time for percutaneous coronary intervention (PCI) in STEMI patients who underwent MVD.
UNASSIGNED: The PubMed/Medline, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to January 1, 2024 for clinical studies comparing immediate multivessel PCI and staged multivessel PCI in patients with STEMI. The primary outcomes were death from any cause, cardiovascular death, noncardiac death, myocardial infarction (MI) and unplanned ischemia-driven revascularization. The secondary outcomes were ischemic stroke, stent thrombosis, renal dysfunction and major bleeding. The risk ratios (RRs) and odds ratios (ORs) were calculated with fixed-effects models and random-effects models, and 95% confidence intervals (CIs) were calculated.
UNASSIGNED: Five randomized trials with 2,782 patients and six prospective observational studies with 3,131 patients were selected for inclusion in this meta-analysis. The staged PCI group had significantly lower pooled RRs for myocardial infarction (0.43, 95% CI = 0.27-0.67; P = 0.0002) and unplanned ischemia-driven revascularization (0.57, 95% CI = 0.41-0.78; P = 0.0004). There were no significant differences in any cause of death, cardiovascular cause of death, or noncardiac cause of death. However, the results of prospective observational studies in the real world indicated that the staged PCI group had significantly lower pooled ORs for all-cause mortality (2.30, 95% CI = 1.22-4.34; P = 0.01), cardiovascular death (2.29, 95% CI = 1.10-4.77; P = 0.03), and noncardiovascular death (3.46, 95% CI = 1.40-8.56; P = 0.007).
UNASSIGNED: According to our randomized trial analysis, staged multivessel PCI significantly reduces the risk of myocardial infarction and unplanned ischemia-driven revascularization compared to immediate multivessel PCI. There was no significant difference between the two groups in terms of all-cause mortality, cardiovascular mortality, or noncardiovascular mortality risk. However, prospective non-randomized studies suggest there might be a benefit in mortality in the staged PCI group. Therefore, staged multivessel PCI may be the optimal PCI strategy for STEMI patients with MVD.

UNASSIGNED: The 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.
UNASSIGNED: This 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.
UNASSIGNED: A 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).
UNASSIGNED: GDF-15 can serve as a biomarker for predicting the development of CMD in STEMI patients undergoing PPCI.

UNASSIGNED: To assess the changes in QRS duration (△QRSd) before and after primary percutaneous coronary intervention(PPCI) regarding the relation of left ventricular ejection fraction (LVEF) in patients after a first acute ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI).
UNASSIGNED: A total of 244 patients with STEMI were enrolled, and clinical, biochemical, and angiographic parameters were compared between two groups based on LVEF at 6 months post-discharge. QRS duration (QRSd) was analyzed in relation to LVEF, and feature selection using least absolute shrinkage and selection operator(LASSO) regression was performed. Logistic regression analysis and receiver operating characteristic (ROC) curve evaluation were conducted to identify predictors and assess model efficacy.
UNASSIGNED: Significant differences were observed between the two groups in terms of various parameters, including age, time from symptom onset to balloon dilation (STB), N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, Left ventricular end-diastolic volume(LVEDV) at baseline, left ventricular end-systolic volume(LVESV)at baseline, left ventricular end-diastolic diameter (LVDD)at baseline and six months, hospital length of stay(days), ST-segment resolution (STR), the left anterior descending artery as the infarction-related artery (IRA-LAD), frequency of TIMI 3 flow post PPCI, thrombus aspiration and/or intracoronary thrombolysis, the use of tirofiban, and the number of implanted stents(stents).In addition, postoperative QRSd and △QRSd were significantly higher in patients with left ventricular systolic dysfunction(LVSD). LASSO regression selected six variables as predictors of postoperative LVEF. Logistic regression analysis identified age, STB, NT-proBNP, LVESV at baseline,△QRSd, and stents, as independent factors associated with LVSD within six months for patients with a first occurrence of STEMI. The models achieved AUC values of 0.906 (using ΔQRSd),0.922(using 6 variables excluding ΔQRSd) and 0.962 (using 6 variables).
UNASSIGNED: This study identified ΔQRSd as a potential predictor of LVSD in patients with STEMI. The developed models showed good efficacy in predicting postoperative LVEF changes. These findings may contribute to risk stratification and individualized management strategies for STEMI patients.

This study explored 1-year follow-up of Parmaco-invasive strategy with half-dose recombinant human prourokinase (PHDP) in patients with acute ST-segment elevation myocardial infarction (STEMI). The follow-up endpoints were major adverse cardiovascular events (MACEs) occurring within 30 days and 1 year, as well as postoperative bleeding events. The study ultimately included 150 subjects, with 75 in the primary percutaneous coronary intervention (PPCI) group and 75 in the PHDP group. This study found that the PHDP group had a shorter FMC-reperfusion time (42.00 min vs 96.00 min, P < 0.001). During PCI, the PHDP group had a lower percutaneous transluminal coronary angioplasty (PTCA) (P = 0.021), intropin (P = 0.002) and tirofiban (P < 0.001) use. And the incidence of intraoperative arrhythmia, malignant arrhythmia, and slow flow/no-reflow was lower in the PHDP group (P < 0.001). At the 30-day follow-up, there was a significantly higher proportion of patients in the PPCI group who were readmitted due to unstable angina (P = 0.037). After 1 year of follow-up, there was no statistically significant difference in MACEs between the two groups (P = 0.500). The incidence of postoperative major bleeding, intracranial bleeding, and minor bleeding did not differ between the PHDP and PPCI groups (P > 0.05). The PHDP facilitates early treatment of infarct-related vessels, shortens FMC-reperfusion time, and does not increase the risk of MACEs.

The Dressler-de Winter sign is an electrocardiogram (ECG) pattern characterized by upsloping ST-segment depression in leads V1-V6 followed by tall, hyperacute T waves, typically indicating an occlusion of the left anterior descending artery (LAD). We present a case involving an inferoposterior ST-segment elevation myocardial infarction (STEMI) with a variant of the de Winter sign, a concept of ST-segment continuum in the precordial leads. Despite initial ECG findings suggesting right coronary artery (RCA) or left circumflex artery (LCX) involvement, coronary angiography confirmed occlusion of the wrap-around LAD distal to the first septal (S1) and diagonal branch (D1) and revealed a left dominant system accompanied by a small non-dominant RCA. This case highlights the diagnostic complexity in accurately localizing the culprit artery in STEMI cases exhibiting the de Winter sign. Understanding such ECG variants is crucial for analyzing the mechanisms of acute ischemia and ensuring accurate assessment of the culprit vessel for effective revascularization.

BACKGROUND: The clinical outcomes of ST-segment elevation myocardial infarction (STEMI) due to the occlusion of left coronary artery are worse in patients with proximal occlusion than in those with non-proximal occlusion. However, there are few reports that focus on the comparison of clinical outcomes in patients with STEMI between proximal and non-proximal right coronary artery (RCA) occlusions.
METHODS: We included 356 patients with STEMI whose infarct-related artery is RCA and divided them into the proximal group (n = 129) and the non-proximal group (n = 227). We defined segment 1 of RCA as proximal, and segments 2, 3, and 4 as non-proximal according to the reporting system of the American Heart Association. The primary endpoint was major cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization.
RESULTS: Incidence of shock at admission, requirement for catecholamine during percutaneous coronary intervention (PCI), or mechanical support during PCI tended to be higher in the proximal group (42.6 %) than in the non-proximal group (33.5 %) (p = 0.088). Although the incidence of right ventricular infarction tended to be higher in the proximal group (17.8 %) than in the non-proximal group (10.6 %) without reaching statistical significance (p = 0.072), the incidence of in-hospital death was similar between the 2 groups (1.6 % versus 1.8 %, p = 1.000). The MACE-free survival curves were not different between the 2 groups (p = 0.400). Multivariate Cox hazard analysis revealed that proximal RCA occlusion was not associated with MACE (HR 1.095, 95%CI 0.691-1.737, p = 0.699).
CONCLUSIONS: Although the acute phase conditions such as shock or right ventricular infarction tended to be more severe in patients with proximal occlusion, overall clinical outcomes including long-term outcomes were comparable between the proximal and distal RCA occlusions. Furthermore, multivariate analysis showed that the proximal RCA occlusion was not associated with MACE after hospital discharge.

BACKGROUND: Pre-hospital heparin administration has been reported to improve prognosis in patients with out-of-hospital cardiac arrest (OHCA). This beneficial effect may be limited to the subgroup of ST-segment elevation myocardial infarction (STEMI) patients.
METHODS: To assess the impact of pre-hospital heparin loading on TIMI (Thrombolysis in Myocardial Infarction) flow grade and mortality in STEMI patients with OHCA, we analyzed data from 2,566 consecutive patients from two hospitals participating in the prospective Feedback Intervention and Treatment Times in ST-segment Elevation Myocardial Infarction (FITT-STEMI) trial.
RESULTS: In 394 participants with OHCA, 272 (69%) received heparin from the emergency medical service (EMS). Collapse witnessed by EMS (odds ratio (OR) = 3.53, 95%-confidence interval (CI) = 1.54-8.09; p = 0.003) and pre-hospital ECG recording (OR = 3.32, 95% CI = 1.06-10.35; p = 0.039) were identified as parameters significantly associated with pre-hospital heparin use. In univariate analysis, in-hospital mortality was lower in the group receiving heparin in the pre-hospital setting (26.8% vs. 42.6%, p = 0.002). However, in a regression model, pre-hospital heparin use was no longer a significant predictor of mortality (OR = 0.992; p = 0.981). Patency of the infarct artery prior to coronary revascularization, as measured by TIMI flow grade, was not associated with pre-hospital administration of heparin in OHCA patients (OR = 0.840; p = 0.724).
CONCLUSIONS: In STEMI patients with OHCA, pre-hospital use of heparin is neither associated with improved early patency of the infarct artery nor with a better prognosis. Our results do not support the assumption of a positive effect of heparin administration in the pre-hospital treatment phase in STEMI patients with OHCA.
BACKGROUND: ClinicalTrials.gov: NCT00794001.

Since the introduction of the first pharmacological therapy for the treatment of patients with acute myocardial infarction in the early 20th century, treatment of myocardial infarction has evolved extensively throughout the years. Mechanical revascularization therapies such as the percutaneous transluminal coronary angioplasty, combined with the ongoing development of pharmacological therapies have successfully improved the survival of patients with acute myocardial infarction. To date, antiplatelet therapy (consisting of aspirin and an oral P2Y 12 inhibitor) and anticoagulation therapy represent the main stay of pharmacological treatment in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The routine use of clopidogrel as antiplatelet agent has been largely replaced by the use of the more potent P2Y 12 inhibitors ticagrelor and prasugrel. Unfractionated heparin remains the preferred anticoagulant therapy, despite the development of other anticoagulants, including enoxaparin and bivalirudin. To date, limited evidence exists supporting a pre-hospital initiation of antiplatelet and anticoagulant therapy in STEMI patients. The use of potent intravenous antiplatelet agents, including the glycoprotein IIb/IIIa inhibitors and the intravenous P2Y 12 inhibitor cangrelor, is currently restricted to specific clinical settings. While several potent antithrombotic agents already exist, the search for novel potent antithrombotic agents continues, with a focus on balancing antithrombotic properties with an improved safety profile to reduce excess bleeding. This review provides an overview of currently available pharmacological therapies for the treatment of STEMI patients undergoing primary PCI, and an outlook for the ongoing development of novel agents in this field.