Impact of Acute Myocardial Ischemia Duration on Reperfusion Outcomes in STEMI Patients

  • Sergii V. Salo National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0001-5456-1418
  • Serhii S. Shpak National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0003-1522-9265
  • Valentyn O. Shumakov SI “National Scientific Center “The M.D. Strazhesko Institute of Cardiology, Clinical and Regenerative Medicine of the National Academy of Medical Sciences of Ukraine”, Kyiv, Ukraine https://orcid.org/0000-0001-5130-8759
Keywords: chest pain, no-reflow phenomenon, myocardial edema, direct stenting, acute coronary syndrome

Abstract

The aim. To analyze the influence of the duration of acute myocardial ischemia, specifically in ST-elevation myocardial infarction (STEMI) electrocardiographic patterns, on the outcomes of reperfusion interventions. We focused on the assessment of immediate angiographic data in the catheterization laboratory after stenting and investigated whether the frequency of the no-reflow phenomenon is dependent on the time since the onset of anginal pain. Our hypothesis of inferior immediate treatment outcomes is based on the pathophysiological course of ischemic-reperfusion injury in patients with late myocardial infarction. Primarily, this is due to the development of myocardial edema, leading to extravascular compression of the vessel, thereby influencing Thrombolysis in Myocardial Infarction grade 0 blood flow.

Materials and methods. We conducted an analysis of 107 angiograms of STEMI patients, who underwent percutaneous coronary intervention at the Amosov National Institute of Cardiovascular Surgery between 2021 and 2023. The patients were categorized into four groups based on the duration of acute myocardial ischemia. The first group included patients with ischemia duration up to two hours, aligning with the golden window for revascularization recommended by the European guidelines. The second, third, and fourth groups consisted of patients with ischemia durations of 3-12 hours, 12-24 hours, and over 48 hours, respectively.

Results. Of 104 patients, complete restoration of coronary circulation was achieved in 88 cases, while, unfortunately, 16 patients had TIMI 0/1 blood flow. Such a probability of complication is 15.3% in the studied cohort. According to the clinical profile, the patients were divided into those who had no-reflow (main group) and patients with complete restoration of blood flow (control group). In the group of unrestored blood flow, cardiogenic shock occurred more often, and the infarct-dependent artery was more often occluded than suboccluded. The technique of percutaneous intervention was similar in both groups.

Conclusion. The frequency of the no-reflow phenomenon increases with the duration of acute myocardial ischemia. Patients presenting later than 48 hours since the onset of ischemia are more prone to no-reflow (62.5% vs 37.5% if less than 48 hours). Cardiogenic shock is associated with a higher likelihood of the no-reflow phenomenon. The most significant reason for the delay in delivering a STEMI patient to catheterization laboratory anamnestically is the patient’s untimely medical care seeking. In our opinion, this delay can be avoided by increasing awareness about the initial signs of myocardial infarction and the necessity of seeking immediate medical care.

References

  1. Marinsek M, Šuran D, Sinkovic A. Factors of Hospital Mortality in Men and Women with ST-Elevation Myocardial Infarction - An Observational, Retrospective, Single Centre Study. Int J Gen Med. 2023 Dec 18;16:5955-5968. https://doi.org/10.2147/IJGM.S439414
  2. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al.; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018;138(20):e618-e651. https://doi.org/10.1161/CIR.0000000000000617
  3. Zoni CR, Mukherjee D, Gulati M. Proposed new classification for acute coronary syndrome: Acute coronary syndrome requiring immediate reperfusion. Catheter Cardiovasc Interv. 2023;101(7):1177-1181. https://doi.org/10.1002/ccd.30667
  4. Hoedemaker NPG, de Winter RJ, Hof AV, Kolkman E, Damman P. Optimal Medical Therapy Prescription in Patients with Acute Coronary Syndrome in the Netherlands: A Multicenter Pilot Registry. Am J Cardiovasc Drugs. 2021;21(2):219-229. https://doi.org/10.1007/s40256-020-00427-9
  5. Heidari F, Rahzani K, Iranpoor D, Rezaee Korosh. The effect of oxygen on the outcomes of non-ST-segment elevation acute coronary syndromes. IJC Metab Endocr. 2017;14:67-71. https://doi.org/10.1016/j.ijcme.2016.12.002
  6. Hashmi KA, Abbas K, Hashmi AA, Irfan M, Edhi MM, Ali N, et al. In-hospital mortality of patients with cardiogenic shock after acute myocardial infarction; impact of early revascularization. BMC Res Notes. 2018 Oct 11;11(1):721. https://doi.org/10.1186/s13104-018-3830-7
  7. Thomaz PG, Moura LA Júnior, Muramoto G, Assad RS. Intra-aortic balloon pump in cardiogenic shock: state of the art. Rev Col Bras Cir. 2017;44(1):102-106. English, Portuguese. https://doi.org/10.1590/0100-69912017001006
  8. Annibali G, Scrocca I, Aranzulla TC, Meliga E, Maiellaro F, Musumeci G. «No-Reflow» Phenomenon: A Contemporary Review. J Clin Med. 2022 Apr 16;11(8):2233. https://doi.org/10.3390/jcm11082233
  9. Chaitman BR, Lim MJ. No reflow and the quest to achieve optimal perfusion during the acute phase of myocardial infarction. J Am Coll Cardiol. 2004;44(2):313-315. https://doi.org/10.1016/j.jacc.2004.04.020
  10. Tobis J. Is no-no-reflow following PCI in AMI due to distal embolization of plaque and thrombus? Catheter Cardiovasc Interv. 2013;82(2):210-211. https://doi.org/10.1002/ccd.25078
  11. Feher A, Chen SY, Bagi Z, Arora V. Prevention and Treatment of No-Reflow Phenomenon by Targeting the Coronary Microcirculation. Rev Cardiovasc Med. 2014;15(1):38-51. https://doi.org/10.3909/ricm0699
  12. Cobas Paz R, Caneiro Queija B, Íñiguez Romo A. No-reflow phenomenon in STEMI: beyond a good angiographic result. Rev Esp Cardiol (Engl Ed). 2022;75(9):706-708. https://doi.org/10.1016/j.rec.2022.02.015
  13. Salo SV, Shumakov VO, Shpak SS, Tokhtarov VV. [Myocardial ischemia – reperfusion injury]. Zaporozhye medical journal. 2023;25(5):455-460. Ukrainian. https://doi.org/10.14739/2310-1210.2023.5.279461
  14. Fan J, Ren M, Adhikari BK, Wang H, He Y. The NLRP3 Inflammasome as a Novel Therapeutic Target for Cardiac Fibrosis. J Inflamm Res. 2022;15:3847-3858. https://doi.org/10.2147/JIR.S370483
  15. Bauer T, Zeymer U, Diallo A, Vicaut E, Bolognese L, Cequier A, et al.; ATLANTIC Investigators. Impact of preprocedural TIMI flow on clinical outcome in low-risk patients with ST-elevation myocardial infarction: Results from the ATLANTIC study. Catheter Cardiovasc Interv. 2020;95(3):494-500. https://doi.org/10.1002/ccd.28318
  16. Tsvetkov H, Mosseri M. Myocardial Blush Grade: An Interventional Method for Assessing Myocardial Perfusion. Isr Med Assoc J. 2008;10(6):465-467.
Published
2023-12-28
How to Cite
Salo, S. V., Shpak, S. S., & Shumakov, V. O. (2023). Impact of Acute Myocardial Ischemia Duration on Reperfusion Outcomes in STEMI Patients. Ukrainian Journal of Cardiovascular Surgery, 31(4), 114-120. https://doi.org/10.30702/ujcvs/23.31(04)/SSh065-114120
Section
GENERAL ISSUES OF TREATMENT OF PATIENTS WITH CARDIOVASCULAR PATHOLOGY