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Background-Ischemic

Angiographic findings of SB, proximal MV stenosis, and clinical presentation are predictive of SB occlusion after MV stenting. Occlusion of sizable SB is associated with adverse clinical outcomes..

Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 ± 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: ≤ 180 min vs long delay group: > 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.

We thank Dr Kong and Dr Morel for their comments on our study.1 However, although the negative findings of the Effects of Postconditioning on Myocardial Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction (POST) trial may result from study design, we do not fully agree with their opinions.First, Dr Kong and Dr Morel claimed that ballooning for ischemic postconditioning should be performed proximal to the culprit lesion rather than within the stent to reduce microembolism. However, there is no direct evidence on association between the location of ballooning for ischemic postconditioning and microembolism or infarct size during primary percutaneous coronary intervention (PCI). Moreover, as we described, the balloon was inflated with low-pressure (<6 atm) inflations to avoid distal embolization.1 On the contrary, to perform iterative balloon angioplasty proximal to the culprit lesion results in geographic mismatch and may increase the risk of target vessel revascularization and myocardial infarction.2 This possible disadvantage of proximal ballooning could not be evaluated in previous small studies. Second, Dr Morel was concerned with the very low rate of direct stenting in our study. However, direct stenting has been reported to be used in fewer than one-third of patients undergoing primary PCI. 3,4Direct stenting is not feasible in some patients with TIMI grade 0 flow because the distal segment beyond the culprit lesion cannot be evaluated. Moreover, no significant benefit of postconditioning was observed in patients undergoing direct stenting in subgroup analysis of the POST trial. He also claimed that the rate of complete ST resolution was very low (41%) in our study. However, the rate of complete ST resolution was reported as 40% to 50% in recent major trials. 5,6 Third, Dr Kong stated that baseline cardiovascular medication may be related to the failure to demonstrate the cardioprotection of postconditioning in PCI and β-blockers may interfere with or even abrogate the infarct size-limiting effect by preconditioning or postconditioning in animal study. We admit that the lack of information on baseline medication may be 1 of the limitations of our study. However, if the benefit of ischemic postconditioning is abrogated by β-blockers, do we have to avoid the use of β-blockers in patients undergoing primary PCI to hold the infarct size-limiting effect by ischemic postconditioning?Our POST trial was a multicenter, prospective, randomized, openlabel, blinded end point trial that was the largest study on the effect of ischemic postconditioning until now. The study population was similar to a majority of primary PCI trials regarding age and sex distribution and symptom onset to reperfusion time.7 Baseline clinical, angiographic, and procedural data were well balanced between the postconditioning group and the control group. Cardioprotective effects of postconditioning were not found in any of the prespecified subgroups. Taken together, we believe that the negative results of the POST trial resul...

In coronary bifurcation lesions, we demonstrated that the 1-stent technique with FKB was associated with a favorable long-term clinical outcome, mainly driven by the reduction of target lesion revascularization in the MV or both vessels as a result of an increase in minimal lumen diameter. (Korean Coronary Bifurcation Stenting Registry II [COBIS II]: NCT01642992).

The 1-stent strategy, if possible, should initially be considered the preferred approach for the treatment of coronary bifurcation lesions, especially LM bifurcation lesions. (Korean Coronary Bifurcation Stenting [COBIS] Registry II; NCT01642992).