The article presents our research results in creating risk group stratification scores in patients with ACS (183 patients) with expecting coronary artery bypass in conditions of heart-lung bypass. These scores based on the complex evaluation of clinical instrumental and biochemical predictors allow to stratify groups of risk and predicting postoperative cardiovascular complications in patients with ACS with expecting coronary artery bypass more effectively than common EuroSCORE.
The aim is to study the effect of microvascular reperfusion injury (RI) of myocardium on structural and functional changes of heart in patients with acute coronary syndrome with ST segment elevation (STE-ACS) and endovascular revascularization. Materials and Methods. The study included 146 patients with STE-ACS (mean age 54 ± 10 years, 89 % men). Depending on the presence of microvascular RI, according to CMR, performed on 5 ± 3 days after myocardial infarction, patients were divided into groups: the first group included 73 patients (50 %) with microvasculature lesions, the second group consisted of 73 patients (50 %) without microvasculature lesions. All patients underwent endovascular myocardial revascularization within 12 hours of symptoms onset. The assessment of structural and functional parameters of heart was performed by CMR with contrast enhancement on 5 ± 3, 30 and 90 days, by echocardiography on 1-2 days, 1, 6 and 12 months after myocardial infarction. Results. In our study microvascular RI was accompanied by a significant size of infarction, a high transmurality index (TI), a large size of edema and a low myocardial salvage index, was associated with LV dilatation, a decrease in global and local myocardial contractility during the 12 months post-infarction period (p < 0.05). The risk of developing pathological remodeling of left ventricle with microvascular RI size >1.2 % of LV mass is OR=6.25, 95 % CI 2.25–17.35 (p < 0.001), myonecrosis size on day 5 ± 3 of MI >11.7 % of LV mass (OR=10.1, 95 % CI 4.72–21.69, p < 0.001), TI > 64.3 (OR=5.63, 95 % CI 2.37–13.39, p < 0.001), edema size >24.7 % of LV mass (OR = 2.33, 95 % CI 1.09–4.97, p < 0.02). Conclusion. Microvascular RI of myocardium is associated with pathological remodeling of the left ventricle.
Aim. To evaluate the informative value of biomarkers (cardiac troponin l (cTnl), high-sensitivity C-reactive protein (hsCRP), N-terminal pro-brain natriuretic peptide (NTproBNP), stimulating growth factor (ST2)) as laboratory markers of myocardial ischemia-reperfusion injury in patients with ST-segment elevation acute coronary syndrome (STEACS) undergoing endovascular revascularization.Material and methods. The study included 115 patients with STEACS who underwent endovascular myocardial revascularization. To identify the informative value of biomarkers, the levels of cTnl, NTproBNP, hsCRP, sST2 were analyzed at baseline, as well as after reperfusion therapy on the 2nd (cTnl) and 5th (sST2, hsCRP, NTproBNP) days. Contrast-enhanced cardiac magnetic resonance imaging was performed 5 days after endovascular intervention.Results. Microvascular obstruction was detected in 54 patients (47%), of which 24 (44%) patients had a combination of microvascular obstruction and myocardial hemorrhage. ln 61 cases (53%), no microvascular damage was registered. lt was found that with an increase in the threshold initial NTproBNP levels >590 pg/ml, the odds ratio (OR) of myocardial reperfusion injury was 12,2 (95% confidence interval (CI), 4,81-30,92, p<0,001). In addition, we analyzed biomarker levels in the early period after myocardial infarction, at which threshold values of reperfusion injury parameters were established as follows: for cTnI >8,1 ng/ml, OR=7,17 (95% CI, 3,11-16,53, p=0,001); for hsCRP >14 mg/L, OR=12,71 (95% CI, 5,03-32,08, p=0,001); for NTproBNP >334 pg/ml, OR=11,8 (95% CI, 4,88-28,59, p=0,001); for sST2 >41 ng/ml, OR=7,17 (95% CI, 3,11-16,53, p=0,001). According to multivariate analysis, predictors of microvascular injury were the initial NTproBNP values, as well as the cTnI, hsCRP, and sST2 values in the early postinfarction period (sensitivity — 89,5%, specificity — 83,3%).Conclusion. Thus, the initial NTproBNP, as well as cTnI, hsCRP, sST2 values after percutaneous coronary intervention are more informative for assessing the risk of microvascular damage.
Введение. Своевременное восстановление кровотока по инфаркт-связанной коронарной артерии (ИСА) является самым эффективным способом ограничения размера инфаркта. Несмотря на несомненность пользы реперфузии в ограничении гибели клеток в условиях тяжелой ишемии, реперфузия может обусловить развитие серьезных побочных реакций, что в свою очередь может уменьшить ее эффективность.Цель. Определить факторы риска развития реперфузионных повреждений миокарда при эндоваскулярной реваскуляризации у пациентов с острым коронарным синдромом с подъемом сегмента ST.Материалы и методы. В исследование включено 52 пациента с острым коронарным синдромом с подъемом сегмента ST, которым проводилась эндоваскулярная реваскуляризация миокарда не позднее 6 часов от начала ангинозных болей. В зависимости от наличия феноменов реперфузионного поражения микроциркуляторного русла (микроваскулярная обструкция (МВО) или «no-reflow» и геморрагическое пропитывание миокарда (ГПМ), выявленных по данным МРТ, пациенты были подразделены на 2 группы. У 23 пациентов 1-й группы после реваскуляризации была выявлена МВО, из них 5 пациентов с МВО и ГПМ, 2-ю группу составили 29 пациентов, у которых не было зарегистрировано поражение микроциркуляторного русла. Всем пациентам проведены клинико-инструментальное (электрокардиограмма, эхокардиография, коронароангиография, МРТ сердца) и лабораторное обследования.Результаты. Не было обнаружено значимых различий между группами по артериальной гипертензии и сахарному диабету, времени от первичного медицинского контакта до реваскуляризации ИСА, количеству пораженных коронарных артерий, исходным показателям SYNTAX, шкалам TIMI и MBG. Поражение микроциркуляторного русла встречалось статистически значимо чаще у активных курильщиков (ОШ=3,48 (1,06–11,3)) и у лиц мужского пола (р<0,05), при передней локализации инфаркта миокарда (ОШ=4,08 (1,25–13,3)), а также у лиц с классом тяжести сердечной недостаточности по Killip ≥2 (ОШ=9,8 (1,09–89,2)) и низким систолическим АД, а также у пациентов при стентировании ПМЖВ (ОШ=5,9 (1,7–20,3)) и при длине имплантируемого стента ИСА ≥24 мм (р=0,04).Заключение. Независимыми дооперационными факторами риска, влияющими на развитие микроваскулярной обструкции при ишемически-реперфузионном повреждении миокарда у пациентов с ОКСпST, являются мужской пол, курение, класс тяжести ОСН по Killip ≥2, низкое систолическое АД, передняя локализация инфаркта миокарда.Интраоперационными факторами риска, способствующими развитию феномена микрососудистого повреждения, являются локализация ИСА в бассейне ПМЖВ, длина имплантируемого стента ИСА (≥24 мм), а также продолжительность коронарной окклюзии (≥246 мин.). Introduction. Timely restoration of blood flow in the infarction-related coronary artery (IRA) is the most effective way to limit the infarction size. Despite the benefits of reperfusion in limiting cell death in severe ischemic conditions, reperfusion can cause serious adverse reactions, which can reduce its effectiveness.Purpose. To determine the risk factors of the development of reperfusion myocardial injury during endovascular revascularization in patients with acute coronary syndrome (ACS) with ST-segment elevation.Materials and methods. The study included 52 patients with ACS and ST-segment elevation, who underwent endovascular myocardial revascularization within 6 hours after the onset of symptoms. Depending on the presence of the phenomena of reperfusion microvascular injury (microvascular obstruction (MVO) or “no-reflow” and intramyocardial haemorrhage (IMH)) revealed by MRI, the patients were divided into 2 groups. In 23 patients of the 1st group, MVO was revealed after revascularization, 5 patients of them had MVO and IMH; the 2nd group consisted of 29 patients without microvascular injury.Results. No significant differences were found between the groups on arterial hypertension and diabetes mellitus, the time from primary medical contact to revascularization, the number of affected coronary arteries, SYNTAX score, TIMI and MBG scales. Тhe phenomena of reperfusion microvascular injury were revealed statistically significantly in active smokers (OR=3.48; 95% CI: 1.06–11.3)) and in male patients (p<0.05), in anterior localization of myocardial infarction (OR=4.08; 95% CI: 1.25–13.3), in Killip class ≥2 (OR=9.8; 95% CI: 1.09–89.2) and low systolic blood pressure, as well as in patients with аnterior descending artery stenting (OR=5.9 (1.7–20.3)) and with the length of the implanted stent in the IRA ≥24 mm (p=0.04).Conclusion. Preoperative risk factors of MVO in patients with ST-segment elevation ACS are the following: male sex, smoking, Killip class ≥2, low systolic blood pressure, anterior myocardial infarction. Intraoperative risk factors of the phenomena of microvascular damage are the following: аnterior descending artery stenting, length of the implanted stent (≥24 mm) and the duration of coronary occlusion (≥246 min).
The article presents a comparative analysis of the results obtained by the invasive treatment in patients with post-infarction angina. In own clinical material authors demonstrate high efficacy of endovascular and surgical treatment carried out in persons with urgent indications Q-myocardial infarction and unstable post-infarction angina. Furthermore, analysis of the frequency and nature of the main causes of complications in various kinds of surgery has been performed. The study found that the development of the final outcome is significantly affected not only by the initial severity of the patient's condition, but also by the selection of the most adequate method of myocardial revascularization. To increase the effectiveness of invasive treatment further improvement and implementation of new technologies of the restoration of coronary blood flow in patients with acute coronary syndrome is offered.
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